Access/correction Request printable pdf download

Access/Correction Request

Municipal Freedom of Information and Protection of Privacy Act

Request for:

Name of Institution Request made to:

☐ Access to General Records

Sarnia Police Service

☐ Access to Own Personal Information

A $5.00 APPLICATION FEE must accompany EACH REQUEST

☐ Correction of Own Personal Information

DETAILS:

Last Name:

First Name:

Middle Name:

Date of Birth:

Address (Street/Apt. No./P.O Box No./R.R. No.)

City or Town:

Province:

Postal Code:

Telephone Number(s):

Area Code:

Mr. ___ Mrs._____

Ms. ___ Miss ____

Please Read:

The record(s) you have requested may contain the personal information fo individuals other than yourself (e.g. victim, accused,

witness). Further to section 21 of the MFIPPA, it may be necessary to notify affected invidiuals before making a decision on access

Do you wish us to contact these inviduals to try and obtain their consent to disclose their information?

No – As I am not requesting access to any other person’s information, I understand that information pertaining to

other individuals will be removed from the records.

Yes As you may be requesting access to another person(s) information, do you consent to our releasing YOUR

identity to the individuals we contact?

Yes ☐ ☐ ☐ ☐

No ☐ ☐ ☐ ☐

Requestor’s Signature: ________________________________________

Carefully explain in detail what record(s) you are requesting access to (names of individuals involved, dates, times, location, incident numbers, officer’s

name & badge number). Please be as specific as you can and request a second sheet if required. If you require assistance, please ask.

Signature:

Date:

Preferred method of

☐ Examine Original

access to records:

☐ Receive Copy

Sarnia Police Use Only

Date received:

Request number:

Identification:

Personal information contained on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy legislation and will be used for the

purpose of responding to your request. Questions about this collection should be directed to the INFOMRATION CLERK (519) 344-8861 ext. 5288.