Fillable THIRD-PARTY ATHORIZATION FORM TO RELEASE STUDENT INFORMATION (University of Ottawa)

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THIRD-PARTY ATHORIZATION FORM TO RELEASE STUDENT INFORMATION (University of Ottawa)

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Notice of Collection of Personal Information
In accordance with the Freedom of Information and Protection of Privacy Act of Ontario and with University Policy 90, your personal information
is collected under the authority of the University of Ottawa Act, 1965. Your personal information provided on this form will be used by the Univer-
sity for purposes of and those consistent with the administration of University programs and activities and in order to carry out other University
services and functions, including recruitment, admission, registration, academic programs, evaluations, nancial aid and awards, assisting
student associations and graduation. If you have questions about the collection, use and disclosure of your personal information in this notice,
please contact InfoService at 613-562-5630 or infoservice@uOttawa.ca.
I have read and understood the information explaining that my personal information will be protected at all times in accordance with the freedom of information and protection of privacy act.
GIVEN NAMES
DATE OF BIRTH
YEAR
VILLE
TEL. NO. &
AREA CODE
MONTH
DAY
STUDENT INFORMATION
LOCAL ADDRESS
(AT HOME)
PROGRAM OF STUDIES
1
2
3
4
5
6
7
8
TEL. NO. &
AREA CODE
SURNAME
PROV. / COUNTRY
(AT WORK)
FACULTY
E-MAIL
STUDENT NO.
APT.
POSTAL CODE
LEVEL
UNDERGRADUATE
@uOttawa.ca
GRADUATE
AUTHORIZED PERSONS
PLEASE INDICATE THE NAME OF THE PERSON(S) TO WHOM YOUR INFORMATION CAN BE RELEASED.
GIVEN NAMES
AUTHORIZED ACTIONS
OBTAIN INFORMATION FROM MY STUDENT RECORD (FINAL MARKS, REGISTRATION HISTORY)
CHANGE MY PROGRAM OF STUDIES
...........................................................................................................................................
REQUEST OFFICIAL DOCUMENTS (TRANSCRIPTS, PROOF OF STUDIES AND OTHER OFFICIAL FORMS OR
DOCUMENTS)
CHANGE MY PERSONAL INFORMATION (E.G., CHANGE OF ADDRESS)
..................................................................................
OBTAIN INFORMATION ON MY REGISTRATION, PROGRAM OF STUDIES, TRANSCRIPT OR DEGREE RECEIVED
PROVIDE OR OBTAIN INFORMATION RELATIVE TO MY ADMISSION FILE
PROVIDE OR OBTAIN INFORMATION RELATIVE TO MY FINANCIAL ACCOUNT
COMMENTS AND RESTRICTIONS
................................................................................
........................................................................
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
SURNAME
DURATION OF THE AUTHORIZATION
START
YEAR
MONTH
DAY
END
YEAR
SIGNATURE (STUDENT)
SIGNATURE
(OFFICE OF THE REGISTRAR / FACULTY)
MONTH
DAY
REGI-3200(E) PDF 2015/07
SIGNA
TURE (STUDENT)
The University of Ottawa has information on file that is available only to you, as a student. This information can only be released with your written permission. You can use this form to authorize one or more
persons (third parties) to access information about you, or to obtain documents or make transactions concerning you.
For fast processing, please sign, scan and send your form from your @uOttawa email address to your faculty or school secretariat or to InfoService. You can also print, complete and bring this form to your
faculty or school secretariat or to InfoService, Tabaret Hall, Room 129, 75 Laurier Avenue East.
CHECK ALL RELEVANT ITEMS
MAKE, CHANGE OR CANCEL MY COURSE SELECTIONS
.............................................................................................................
NO. AND
STREET
OFFICE OF THE REGISTRAR OR FACULTY REPRESENTATIVE
CANCELLATION OF AUTHORIZATION
YOU CAN CANCEL PREVIOUS AUTHORIZATIONS BELOW BY SIGNING YOUR NAME AND INCLUDING THE DATE.
DATE
DATE
DATE
Université d’Ottawa
|
University of Ottawa
Oce of the Registrar / InfoService
75, Laurier East avenue, Ottawa (Ontario) Canada K1N 6N5
THIRD-PARTY AUTHORIZATION FORM TO RELEASE STUDENT INFORMATION
9
PROVIDE OR OBTAIN INFORMATION RELATIVE TO MY UNIVERSITY OF OTTAWA SCHOLARSHIPS
....................................
YES NO
.......................................
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THIRD-PARTY ATHORIZATION FORM TO RELEASE STUDENT INFORMATION (University of Ottawa)

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Completed 20 January 2021

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