Authorization of Representative

Application: POPA and ATIA Authorization of Representative

Submit a Request

This form authorizes a representative to act on your behalf in matters involving Sturgeon County. This may include making requests under the Protection of Privacy Act (POPA) or the Access to Information Act (ATIA).

Submitter Name(Required)

First Last

Submitter Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Authorized Representatives Name(Required)

First Last

Authorized Representatives Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

I authorize my representative to exercise:(Required)

Select applicable options

all my rights under the Protection of Privacy Act (POPA) and the Access to Information Act (ATIA).

my right to access all my records containing personal information in all categories of personal information

my right to access all the following records containing personal information or all the following categories of personal information (number and titles of records or categories):

the rights that I have under ATIA and POPA regarding the following other matters (e.g. consent to disclose personal information):

You selected 'my right to access all the following records containing personal information or all the following categories of personal information'

Please indicate the number and titles of records or categories.

You selected 'the rights that I have under ATIA and POPA regarding the following other matters'

Please explain (e.g. consent to disclose personal information):

I confirm that my representative has the authority to exercise the above right(s) under the ATIA and POPA for me. This authorization will be in effect until(Required)

Name(Required)

First

Signature(Required)

Witness Name(Required)

First

Witness Signature(Required)

Date(Required)

Sturgeon County collects the personal information on this form for the purpose of confirming and authorizing your designated representative to act on your behalf in matters involving the County under the Protection of Privacy Act (POPA) and the Access to Information Act (ATIA). This collection is authorized under section 4(c) of the Protection of Privacy Act. If you have any questions about the collection or use of this information, please contact the Access and Privacy advisor at accessandprivacy@sturgeoncounty.ca or by phone at 780-939-4321

Authorization of Representative

Application: POPA and ATIA Authorization of Representative

Submit a Request

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