Hamilton Civic League

Personal Information Access Request Form

PART A: Requestor Identification

_______________________________ _______________________________ _____

Last Name First Name Initial

________________________________________________________________________

Mailing Address

_______________________________

Telephone

PART B: Requesting access to personal information held by Hamilton Civic League

1. Please describe what you need and include details that will help us locate the personal

information (e.g., dates, nature of your relationship with Hamilton Civic League, etc.).

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

2. How would you prefer to access this information? Please check off:

Receive hard copies of originals o Examine originals in our office o

Signature Printed Name Date

Please mail this form to: Privacy Officer at the mailing address for Hamilton Civic League (available on our web site).

INFORMATION AND INSTRUCTIONS

The Hamilton Civic League will provide you with access to your personal information, unless a legal exception applies. We will review all information access requests, and will make every effort to respond to your request in a timely fashion.

Please complete Parts A and B of this Form. Part C is for our internal use.

For information about our privacy protection practices, contact the Privacy Officer at the above address.

For Internal Use ONLY

PART C: Response to Access to Personal Information Request

1. Date Request Received:_____________________________

Date Limit for Response: ______________________________

A response will be provided within 30 days after receipt of the request

2. Date Response Issued: _____________________________

o Access request granted

o Access request not granted

o Access request granted in part

If access request was not granted or granted in part only, give reason for not providing the information.

______________________________________________________________________

______________________________________________________________________

3. Extension

If an extension to the access request response was required, please complete the following:

Date of Extension: ____________________________

Date Limit for response: ________________________ (Maximum of 30 additional days)

Requestor advised of extension on: ____________________________

Reason for extension: __________________________________________________

____________________________________________________________________

4. Access Request processed by:

____________________________ _________________________________

Printed Name Title

____________________________

Signature