Application for Access to a Record

About

This is an application pursuant to the Freedom of Information and Protection of Privacy Act for access to

Applicant's own personal information.

Other information.

Both applicant's own personal information and other information.

I am applying for access to the following record

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 et cetera), 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.)

I wish to:

Examine the record.

Receive a copy of the record.

I understand that I may be required to pay a fee before obtaining access to the record

Payment of any fees:

I agree to pay any fees associated with this request.

I hereby request to be excused from paying fees related to this application because I cannot afford to pay fees.

I hereby request to be excused from paying fees related to this application because (specify another reason).

Specify another reason

Applicant’s Contact Information

Applicant’s Full Name

Applicant’s Email Address

Applicant’s Phone Number

Applicant’s Facsimile Number

Address of Applicant

Country

Street address

City

Province

Postal code

Patient Education Library

Application for Access to a Record

About