Subject Disclosure Request Form
Name of individual
*
First Name
Middle Name
Last Name
Date of Birth of individual
*
-
Day
-
Month
Year
Date
Previous name of individual (if applicable)
First Name
Middle Name
Last Name
Please provide information about the service(s) the person received from us, and if known their unique ID (Salesforce) number given.
Reason for the request
*
Requested information
*
Organisation name & address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requester name
*
First Name
Last Name
Requester job position
*
Requester email address
*
example@example.com
Requester phone number
*
-
Area Code
Phone Number
Will the individual provide consent?
*
Yes
No
Provide the GDPR Section you are relying on for consent exemption
Please upload a consent form signed by the individual, this document should also contain a copy of their photo ID
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Preferred required by date
-
Day
-
Month
Year
Date
How would you like to receive the response?
*
Secure Email
Post
Upload a copy or photo of your professional ID card, or alternative relevant documentation (e.g. a court order)
*
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I confirm that I am authorised to request a Subject Disclosure on behalf of my organisation
*
Yes
Requester signature
Submit
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