Hospis Malaysia Personal Data Access Request Form printable pdf download

Hospis Malaysia Personal Data Access Request Form

HOSPIS MALAYSIA PERSONAL DATA ACCESS REQUEST FORM

[1]

ABOUT YOU

Full name: ___________________________________________________________

NRIC/Passport Number: ___________________________

Address: ____________________________________________________________

Telephone number: _______________________________

Fax number: ____________________________________

E-mail address: _______________________________________________________

[2]

ARE YOU REQUESTING FOR YOUR OWN PERSONAL DATA? IF YES, PLEASE

PROCEED TO ANSWER PART (A) BELOW.

ARE YOU A THIRD PARTY REQUESTING FOR ACCESS TO SOMEONE ELSE’S

PERSONAL DATA? IF YES, PLEASE PROCEED TO ANSWER PART (B) BELOW.

PART A

[a]

Please state the nature of your relationship with Hospis Malaysia:

[ ]

A current* / former patient* of Hospis Malaysia

[ ]

A current* / former employee* of Hospis Malaysia

[ ]

A current* / former* donor, vendor, service provider or supplier of Hospis

Malaysia

(* delete where applicable)

[b]

Please also provide a photocopy of your National Registration Identification Card

(NRIC) or the first page your passport containing your personal details for us to verify

your identity. Please mark the photocopy of your NRIC or passport with “FOR

PERSONAL DATA ACCESS REQUEST ONLY”

PART B

[a]

Please provide a signed photocopy of your National Registration Identification Card

(NRIC) or your passport for us to verify your request.

Please state the nature of the Data Subject’s

[b]

relationship with Hospis Malaysia

[ ]

A current* / former patient of Hospis Malaysia

[ ]

A current* / former* employee of Hospis Malaysia

[ ]

A current* / former* donor, vendor, service provider or supplier of Hospis

Malaysia

(* delete where applicable)

i.e. Are you requesting access to your own information OR are you a third party requesting access to someone

else’s information?

“Data Subject” means the individual who is the subject of the personal data.

Hospis Malaysia Personal Data Access Request Form

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