Form B (NWT8714) "Consent for the Release of Information" - Northwest Territories, Canada

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NWT Student Financial Assistance
FORM B - CONSENT FOR THE RELEASE OF INFORMATION
Use this form if you wish to have someone else access your NWT Student Financial Assistance (SFA) information on your
behalf during the current academic year. Please note that this form must be completed each year.
STUDENT INFORMATION
First and Last Name
Date of Birth - YY/MM/DD
Email Address
RELEASE INFORMATION TO
First and Last Name
Relationship
INFORMATION TO BE RELEASED
Type of information you want SFA to release to this person during this current academic year:
All or
Please Explain:
DECLARATION OF CONSENT
I hereby consent to the release of the information referred to above from my file by the Department of Education,
Culture and Employment. No other person(s) will be given this information without my further written consent and
this information will be used only as stated above.
X
Signature
Date - YY/MM/DD
SFA PID
nwtsfa@gov.nt.ca
www.nwtsfa.gov.nt.ca
This information is being collected under the authority of the Access to Information and Protection of Privacy (ATIPP) Act, Section 41.(1)(g) and the Northwest Territories Student Financial
Assistance (SFA) Act and Regulations. The information will be used to determine my initial and continued eligibility for SFA and for the general administration and enforcement of this program.
The privacy provisions of the ATIPP Act protect my information, and all applicants have the right to examine and request correction of his or her records and to request a review by the Information
and Privacy Commissioner. If you have any questions about the collection of information, contact the SFA Manager, Department of Education, Culture and Employment, Box 1320, Yellowknife,
NT X1A 2L9, or call 1-800-661-0793 or 1-867-767-9355.
PAGE 1 OF 1
NWT8714/0617
NWT Student Financial Assistance
FORM B - CONSENT FOR THE RELEASE OF INFORMATION
Use this form if you wish to have someone else access your NWT Student Financial Assistance (SFA) information on your
behalf during the current academic year. Please note that this form must be completed each year.
STUDENT INFORMATION
First and Last Name
Date of Birth - YY/MM/DD
Email Address
RELEASE INFORMATION TO
First and Last Name
Relationship
INFORMATION TO BE RELEASED
Type of information you want SFA to release to this person during this current academic year:
All or
Please Explain:
DECLARATION OF CONSENT
I hereby consent to the release of the information referred to above from my file by the Department of Education,
Culture and Employment. No other person(s) will be given this information without my further written consent and
this information will be used only as stated above.
X
Signature
Date - YY/MM/DD
SFA PID
nwtsfa@gov.nt.ca
www.nwtsfa.gov.nt.ca
This information is being collected under the authority of the Access to Information and Protection of Privacy (ATIPP) Act, Section 41.(1)(g) and the Northwest Territories Student Financial
Assistance (SFA) Act and Regulations. The information will be used to determine my initial and continued eligibility for SFA and for the general administration and enforcement of this program.
The privacy provisions of the ATIPP Act protect my information, and all applicants have the right to examine and request correction of his or her records and to request a review by the Information
and Privacy Commissioner. If you have any questions about the collection of information, contact the SFA Manager, Department of Education, Culture and Employment, Box 1320, Yellowknife,
NT X1A 2L9, or call 1-800-661-0793 or 1-867-767-9355.
PAGE 1 OF 1
NWT8714/0617