CONSENT TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY Last Revised June 2017
Consent to Disclose Personal
Information to a Third Party
Your written consent authorizes Advanced Education to disclose your personal information to a designated individual in accordance with s.40(1)(d) of the
Freedom of Information and Protection of Privacy Act (Alberta). If you have any questions regarding the disclosure of information, contact the Alberta Student
Aid Service Centre toll free at 1-855-606-2096 from anywhere in North America. You can also mail your questions to Alberta Student Aid, Privacy Ofcer,
PO Box 28000 Stn Main, Edmonton AB T5J 4R4.
Use this Consent to Disclose Personal Information to a Third Party Form to give Advanced Education permission to share your personal information with
a third party. If you want to give a third party permission to take action on your behalf, complete a Power of Attorney Form. If you are studying outside
of Canada, submit this form before you leave Alberta. Give a completed copy to the authorized third party and keep a copy for your records.
To complete a fillable form: 1. Save to your desktop. 2. Complete form. 3. Save nal. Check, then submit. Never complete in a browser.
Authorization Information
Alberta Student Number
I, ______________________________________________________________________________________________________
authorize Advanced Education to disclose information, including my personal information, to:
________________________________________________________________________________________________________ (the “Third Party”)
about:
all information on my student aid le OR:
Notwithstanding the authorization above, I do not consent to Advanced Education disclosing the following information to the Third
Party (list any particular pieces of information that you do not authorize the Third Party to obtain, e.g. do not share my income from my
tax return, previous application history, etc.):
I understand this form does not permit the Third Party named above to take any steps regarding management of the information
of my student aid le or to give information or instructions to Advanced Education on my behalf.
This consent is valid until:
You may withdraw this consent at any time by sending a request to do so in writing to Alberta Student Aid.
Signature of Student
✗ SIGN HERE
Student’s Full Legal Name (rst name, middle initial, last name)
Full Legal Name (rst name, middle initial, last name) of person to whom information will be disclosed
only the current status of my student aid application(s)
only my disbursement and/or my repayment schedule
only the following information on my le:
the completion of my current funded study period
a specic expiration date: (e.g. the expected end date of your program.)
Day Month Year
Note: The maximum time that this consent can be valid for
is 10 years. If you do not select an option, your consent will
expire 365 days from the date you sign, below.
Today’s Date
Day Month Year
Send documents electronically: 1. Visit studentaid.alberta.ca 2. Sign in to your account 3. Submit securely using Upload Electronic Document(s)
Or mail to: Alberta Student Aid, PO Box 28000 Stn Main Edm AB T5J 4R4
