Access to Information and Privacy Office
550 Cumberland Street, Room M407
Ottawa, ON K1N 6N5
Tel.: 613-562-5800 (1851)
Fax: 613-562-5112
[email protected]
Authorization Request Form for
Representation
Part 1 - Requester’s Information
Mr.
Family name *
Ms.
Unit/Apt.no
First and middle name(s) *
Street no. *
Street name *
City *
PO Box
Province *
Home phone no.
Postal code *
Work phone no.
Cell phone no.
E-mail address
Part 2 – Representative Information (to be completed only if you will be represented)
Representative is a:
Lawyer
Agent
Name of Company, Association or Organization, if applicable:
First and middle names
Family name
Unit/Apt.no
Street no.
PO Box
Street name
City
Province
Daytime telephone no.
Postal code
E-mail address
Part 3 - Consent
I authorize my representative to:
Communicate on my behalf on all matters relating to the processing of my FIPPA request.
I authorize and direct the University of Ottawa to:
Send all communications related to my FIPPA request to my representative.
Release the records to my representative in accordance with the University’s decisions relating to access and subject to the payment
of applicable fees.
______________________________________________
Signature
________________________________
_ Date (yyyy/mm/dd)
* REQUIRED FIELD
PLEASE SEND YOUR COMPLETED FORM TO THE ADDRESS ABOVE. THANK YOU.
Personal information contained on this form is collected pursuant to Freedom of Information and Protection of Privacy Act and will be used for the purpose
of responding to your request. Questions about this collection should be directed to the Director, Compliance, Access to Information and Privacy, Access to
Information and Privacy Office, University of Ottawa, Tabaret Hall, 550 Cumberland Street, Room M407, Ottawa, Ontario, K1N 6N5.