Request for Access to Records | District of Port Edward

You may make a request for access to records without using this form, provided you do so in writing. Personal information contained on this form is collected under the Freedom of Information and Protection of Privacy Act and will be used only for the purpose of responding to your request. There may be a cost associated with this request.

YOUR NAME

Last Name*:

First Name*:

Middle Name:

Preferred Prefix*:

YOUR ADDRESS

Street Address*: Street, Apt #, PO Box, RR No.

City / Town*:

Province / Territory*:

Postal Code*:

YOUR TELEPHONE / FAX NO.(s) (incl. area code)

Day Phone*: ###-###-####

Email Address*:

Fax*:

DETAILS OF REQUESTED INFORMATION

Details of Your Request*: Please describe the records you are requesting. Be as specific as possible, as this will assist the Request process. Attach a separate sheet, if the space above is not sufficient.

Please specify any Ref # or File #, if known.*:

Are you requesting access to another person’s personal information?

Yes

If so, please attach, as appropriate:

That person’s signed consent for disclosure, or
Proof of authority to act on that person’s behalf

Attach file: Accepted file formats: .pdf, .doc, .docx, .jpg, .jpeg, .gif

Preferred method of access to records*

Examine Original

Receive Copy

Agree to collection of personal information*

The personal information submitted in this form is collected in accordance with Section 26 (c, d, e) of the British Columbia Freedom of Information and Protection of Privacy Act (FOIPPA) (the “Act”) and will be used for the purpose of the Request of Access to Records Application. Please be advised that the District of Port Edward is a “public body” as defined in the Act. Questions about the collection, use and disclosure of this information can be directed to the District of Port Edward’s Corporate Office at 250-628-3667 or .

Date of Submission: