SC INS3124 (2015-07-002) E
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Service
Canada
PROTECTED WHEN COMPLETED - B
INDIVIDUAL'S CONSENT TO DISCLOSURE
AND/OR USE OF PERSONAL INFORMATION
I,
(Name of individual) File / Identifying Number
DO HEREBY CONSENT TO THE DISCLOSURE AND/OR USE OF THE FOLLOWING ELEMENTS OF MY PERSONAL INFORMATION, SPECIFICALLY:
SOLELY FOR THE PURPOSE OF:
FOR WHICH PURPOSE MY PERSONAL INFORMATION HAS BEEN REQUESTED BY AND MAY BE DISCLOSED TO:
(Identity and address of the body or person authorized to receive and/or use this information)
Signature
Date
The Personal Information is collected under the authority of the Employment Insurance Act for the purpose mentioned below.
Your personal information is administered in accordance with the Employment Insurance Act, Department of Employment and Social
Development Act and the Privacy Act. You have the right to the protection of, and access to, your personal information. It will be retained in
the Personal Information Bank ESDC PPU 150 “Insurance Claim File-Local Office” and will be used and disclosed in accordance with the
conditions listed therein and retained for the period of time required by the Employment Insurance Act and Library and Archives Act.
You are not obligated by Employment and Social Development Canada to complete this form. You may however use this form to authorize
disclosure of your personal information.
