Form YG6665 "Authority to Release Personal Information to a Designated Individual" - Yukon, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form YG6665 "Authority to Release Personal Information to a Designated Individual" - Yukon, Canada

Download PDF

Fill PDF online

Rate (4.3 / 5) 11 votes
YUKON NOMINEE PROGRAM, YUKON TEMPORARY FOREIGN
WORKER PROGRAM, YUKON BUSINESS NOMINEE PROGRAM
AUTHORITY TO RELEASE PERSONAL INFORMATION
TO A DESIGNATED INDIVIDUAL
This form is for foreign nationals who wish to authorize the Yukon Nominee Program, Yukon Temporary Foreign Worker
Program or Yukon Business Nominee Program to release their personal information to an individual they designate.
The individual you designate will be able to obtain information on your case file, such as the status of your application.
However, the individual will not be a representative who can conduct business on your behalf with the Yukon Nominee
Program, Yukon Temporary Foreign Worker Program or Yukon Business Nominee Program.
Choose one:
I authorize the Yukon Nominee Program, Yukon Temporary Foreign Worker Program or Yukon Business Nominee
Program to release information from my file to the individual designated below.
I withdraw my authorization to release information from my file to the individual designated below.
1. YOUR INFORMATION
Last name (surname)
First name(s)
Date of birth
Y Y Y Y
/
M M
/
D D
2. EMPLOYER INFORMATION (for the Yukon Nominee or Yukon Temporary Foreign Worker Programs only)
Business name
Officer with signing authority for this business
3. YOUR DESIGNATED INDIVIDUAL’S INFORMATION
Last name (surname)
First name(s)
Name of business or organization (if applicable)
Mailing address
City
Province/State/Territory
Country
Postal/zip code
Country code
Area code and phone number
Email (if applicable)
Relationship to the foreign national
Access to Information and Protection of Privacy Act: This information is collected for the purpose of administering an economic development program pursuant to
Section 8 and 9 of the Economic Development Act, as amended. Personal information on this form is collected under the authority of Section 29(c) of the Access to
Information and Protection of Privacy (ATIPP) Act for the purpose of carrying out a program and/or providing financial assistance to the applicant. The collection, use, and
disclosure of your personal information are managed in accordance with the ATIPP Act and all or part of this information may be made available to the public. For more
information about the collection, use and disclosure of your personal information, please contact the Department of Economic Development’s ATIPP coordinator/records
officer 867-667-5946, or privacy officer/director of Finance, Administration and Systems 867-667-5933.
YG(6665EQ)F2 01/2019
Page 1 of 2
YUKON NOMINEE PROGRAM, YUKON TEMPORARY FOREIGN
WORKER PROGRAM, YUKON BUSINESS NOMINEE PROGRAM
AUTHORITY TO RELEASE PERSONAL INFORMATION
TO A DESIGNATED INDIVIDUAL
This form is for foreign nationals who wish to authorize the Yukon Nominee Program, Yukon Temporary Foreign Worker
Program or Yukon Business Nominee Program to release their personal information to an individual they designate.
The individual you designate will be able to obtain information on your case file, such as the status of your application.
However, the individual will not be a representative who can conduct business on your behalf with the Yukon Nominee
Program, Yukon Temporary Foreign Worker Program or Yukon Business Nominee Program.
Choose one:
I authorize the Yukon Nominee Program, Yukon Temporary Foreign Worker Program or Yukon Business Nominee
Program to release information from my file to the individual designated below.
I withdraw my authorization to release information from my file to the individual designated below.
1. YOUR INFORMATION
Last name (surname)
First name(s)
Date of birth
Y Y Y Y
/
M M
/
D D
2. EMPLOYER INFORMATION (for the Yukon Nominee or Yukon Temporary Foreign Worker Programs only)
Business name
Officer with signing authority for this business
3. YOUR DESIGNATED INDIVIDUAL’S INFORMATION
Last name (surname)
First name(s)
Name of business or organization (if applicable)
Mailing address
City
Province/State/Territory
Country
Postal/zip code
Country code
Area code and phone number
Email (if applicable)
Relationship to the foreign national
Access to Information and Protection of Privacy Act: This information is collected for the purpose of administering an economic development program pursuant to
Section 8 and 9 of the Economic Development Act, as amended. Personal information on this form is collected under the authority of Section 29(c) of the Access to
Information and Protection of Privacy (ATIPP) Act for the purpose of carrying out a program and/or providing financial assistance to the applicant. The collection, use, and
disclosure of your personal information are managed in accordance with the ATIPP Act and all or part of this information may be made available to the public. For more
information about the collection, use and disclosure of your personal information, please contact the Department of Economic Development’s ATIPP coordinator/records
officer 867-667-5946, or privacy officer/director of Finance, Administration and Systems 867-667-5933.
YG(6665EQ)F2 01/2019
Page 1 of 2
4. YOUR DECLARATION
4A. If you are giving authorization:
I authorize the Yukon Nominee Program, Yukon Temporary Foreign Worker Program or the Yukon Business
Nominee Program to release information from my file to the individual named above.
I understand that this consent only allows the disclosure of my personal information and that of my dependent
children as defined in the Yukon Nominee Program, Yukon Temporary Foreign Worker Program or Yukon Business
Nominee Program’s policies.
I further authorize the designated individual to update the address listed in my file as required.
I am aware that any information released is subject to the Access to Information and Protection of Privacy Act (ATIPP).
I understand the above statements, having asked for and obtained an explanation for every point that was not
clear to me.
I declare that the information I have given is truthful, complete and correct.
4B. If you are withdrawing your authorization:
I withdraw my authorization to release information from my case file to the individual named above.
Signature of applicant
Date
Y Y Y Y
/
M M
/
D D
Signature of designated individual
Date
Y Y Y Y
/
M M
/
D D
Signature of employer
Date
Y Y Y Y
/
M M
/
D D
Page 2 of 2
Print
Clear
Page of 2