Consent

Authorization and Consent for Disclosure of Personal Information

Patricia Arab

MLA, Fairview-Clayton Park

IMPORTANT NOTICE
This form authorizes the release of your personal information to Patricia Arab, MLA for Fairview-Clayton Park and her staff.
Express Consent*
I consent to the disclosure of personal information about me with respect to each of these selected items:
- Nova Scotia Department of Community Services
- Nova Scotia Department of Health and Wellness
- Nova Scotia Department of Education and Early Childhood Development
- Nova Scotia Department of Labour, Skills and Immigration
- Worker’s Compensation Board
- Maintenance Enforcement Program
- Service Nova Scotia and Municipal Relations
- Metropolitan Housing Authority
- Other (specify below)
Department or Organization*
Example: Department of Business or Nova Scotia Power.
Date of Birth
Please provide your date of birth for Metropolitan Housing Authority related requests.
MM slash DD slash YYYY
ADDITIONAL NOTICE

I also consent to Patricia Arab, MLA for Fairview-Clayton Park and her staff using my personal information until the matter is resolved or until I revoke this consent.

Your personal information, whether on paper or in electronic form, will only be used for the purpose of resolving this specific issue. The information will be stored securely and will only be accessed by authorized staff. The records will be destroyed per our document retention and secure destruction policy at a future point.
Client Name*
First Last
Client Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Email*
E-SIGNATURE

This form will not be processed without a signature. The electronic signature can be added using your finger or a stylus on a touchscreen device or with your mouse on a computer.

Your electronic signature is legally binding, just as a written signature granted in person.
Signature*

Authorization and Consent for Disclosure of Personal Information

IMPORTANT NOTICE

ADDITIONAL NOTICE

E-SIGNATURE

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