Request for Access to Records - Freedom of Information & Protection of Privacy Contact Title Title - None -MissMsMrMrsDrOther… Enter other… First Middle Last Address Address City/Town State/Province ZIP/Postal Code Email Phone DETAILS OF REQUESTED INFORMATION Please specify the name of the department or program area responsible for the records you are requesting. Please specify any Ref# or File#, if known. Information requested (please describe the records you are requesting). Be as specific as possible, as this will assist the request process. Preferred Method of Access to Records Book appointment to view originals Receive copies Your Signature Sign above Date Signed 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.