"Tourism Business Mentorship Program Mentee Consent to Collection and Disclosure of Personal Information (Stream 1)" - Northwest Territories, Canada

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Tourism Business Mentorship Program
Mentee Consent to Collection and Disclosure of Personal
Information (Stream 1)
The personal information you provide on the Tourism Business Mentorship Program
Collection
Mentee Application Form (Stream 1) (Application Form) is being collected under the
authority of section 40(c) of the Northwest Territories Access to Information and Protection
of Privacy Act (the Act) for the purpose of assessing your application for participation in the
Tourism Business Mentorship Program as a mentee. The personal information collected on
the Application Form is protected under the privacy provisions of the Act.
If you consent, the information collected on the Application Form may be disclosed as set
Disclosure
out below. You are allowed to refuse to sign this consent form and doing so will have no
adverse effect on your ability to participate in this program.
I,
, authorize the Department of Industry, Tourism
and Investment (ITI) to disclose the personal information collected on the Application
Form for the following purposes:
1. To the Canadian Executive Services Organization for use in matching me with my
mentor; and
2. To my mentor.
I,
, further authorize ITI to disclose my name,
participation in the program, and which mentor I am matched with for the following
purposes:
1. In an annual Grant and Contributions Report, which is published on ITI’s website;
2. In an annual report to the Standing Committee on Economic Development and
Environment; and
3. To members of the Northwest Territories Legislative Assembly.
If you have any questions about the collection, use or disclosure of your personal
information, contact the Access and Privacy Coordinator of ITI at 1-867-767-9202 x 63035.
I hereby give my consent, dated
Print name - mentee
Signature of mentee
Tourism Business Mentorship Program
Mentee Consent to Collection and Disclosure of Personal
Information (Stream 1)
The personal information you provide on the Tourism Business Mentorship Program
Collection
Mentee Application Form (Stream 1) (Application Form) is being collected under the
authority of section 40(c) of the Northwest Territories Access to Information and Protection
of Privacy Act (the Act) for the purpose of assessing your application for participation in the
Tourism Business Mentorship Program as a mentee. The personal information collected on
the Application Form is protected under the privacy provisions of the Act.
If you consent, the information collected on the Application Form may be disclosed as set
Disclosure
out below. You are allowed to refuse to sign this consent form and doing so will have no
adverse effect on your ability to participate in this program.
I,
, authorize the Department of Industry, Tourism
and Investment (ITI) to disclose the personal information collected on the Application
Form for the following purposes:
1. To the Canadian Executive Services Organization for use in matching me with my
mentor; and
2. To my mentor.
I,
, further authorize ITI to disclose my name,
participation in the program, and which mentor I am matched with for the following
purposes:
1. In an annual Grant and Contributions Report, which is published on ITI’s website;
2. In an annual report to the Standing Committee on Economic Development and
Environment; and
3. To members of the Northwest Territories Legislative Assembly.
If you have any questions about the collection, use or disclosure of your personal
information, contact the Access and Privacy Coordinator of ITI at 1-867-767-9202 x 63035.
I hereby give my consent, dated
Print name - mentee
Signature of mentee