Fillable DALHOUSIE UNIVERSITY Application for Access to a Record (Dalhousie University)

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DALHOUSIE UNIVERSITY Application for Access to a Record (Dalhousie University)

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1
DALHOUSIE UNIVERSITY
Application for Access to a Record
Freedom of Information and Protection of Privacy Act (FOIPOP)
Subsection 6(1)
TO:
FOIPOP Coordinator
Dalhousie University
Room 225, Henry Hicks Academic Administration Building
PO Box 15000
Halifax, Nova Scotia B3H 4R2
The following form may be used to make an application to Dalhousie University under the
Freedom of Information and Protection of Privacy (FOIPOP) Act. When completing the form,
please provide as much information as possible regarding the records you are seeking in order
that we may determine whether the records exist and where they are located.
If you require any assistance in completing this form or have any questions concerning
FOIPOP, please contact Dalhousie University. Once the form is completed and signed by you,
please send or deliver it along with your $5.00 application fee (cash or cheque made payable to
“Dalhousie University”, unless you are seeking personal information about yourself in which
case the fee is not payable) to:
FOIPOP Coordinator
Dalhousie University
Room 225, Henry Hicks Academic Administration Building
PO Box 15000
Halifax, Nova Scotia
B3H 4R2
Phone: (902) 494-2184
Email: FOIPOP@dal.ca
1. This is an application pursuant to the Freedom of Information and Protection of Privacy Act
for access to: (Check one)
_____ (a) applicant’s own personal information (no fee required); or
_____ (b) other information ($5.00 fee required); or
_____ (c) both applicant’s own personal information and other information ($5.00 fee
required)
2. I am applying for access to the following record:
(Below, identify the material applied for precisely by including such particulars as the specific
event or action to which it refers, the date of the record or the date or period to which it relates,
the type of record (document, report, letter, etc.), names of department personnel who prepared
or may have knowledge of the information, or citations to newspapers or publications which are
known to have referred to the record. Use additional pages as appropriate to assist in
identifying the record.)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
2
____________________________________________________________________________
3. I wish to(Check one):
_____ (a) examine the record; or
_____ (b) receive a copy of the record
4. I understand that I may be required to pay a fee before obtaining access to the record.
Date: ______________________________________
Signature of Applicant: ______________________________________________
(Type name for Digital Signature)
Full Name of Applicant (Print): _____________________________________________
Mailing Address of Applicant: _________________________________________________
(Street / Apartment No / RR #)
_________________________________________________________________________
(City / Community) (Province) (Postal Code)
Contact Numbers for Applicant: _______________________/______________________
(Residence / Business)
If you would like us to communicate with you by email, please provide your email address
below:
____________________________
========================================================================
Request to Waive Additional Fees
I hereby request to be excused from paying additional fees related to the above application
because:
_____ (a) I cannot afford to pay fees; or
_____ (b) (specify any other reason)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
For office Use Only:
FOIPOP #___________________
Date Application Received_______________________
Application Fee Received Y__ N___ Not Required____ Not Sent ___
Date Application Fee Received if required: ___________________________
Clarification Required? Y___ N____
Client Notified Y__ N __ Date Notified _____________________
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DALHOUSIE UNIVERSITY Application for Access to a Record (Dalhousie University)

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Completed 13 October 2021

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