Data Subject Access Request (DSAR) Form

DATA SUBJECT ACCESS REQUEST (DSAR) FORM
DATA SUBJECT'S DETAILS
Name:*

First NameLast Name
Contact Telephone Number:*

Area CodePhone Number
Email Address:*
example@example.com
Postal Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DETAILS OF PERSON REQUESTING THE INFORMATION (IF NOT THE DATA SUBJECT).IF YOU ARE THE DATA SUBJECT I.E. THE PERSON REQUESTING THE INFORMATION ON YOUR OWN BEHALF, YOU DO NOT NEED TO COMPLETE THE SECTION BELOW:
Are you acting on behalf of the data subject with their written authority or other legal authority (please tick)?*

YesNoN/A if a data subject
If ‘yes’ please state your relationship with the data subject and supply certified proof i.e. Relevant Power of Attorney, Deputyship, Grant of Probate/Copy of Will/Letters of Administration: (Please state n/a if non applicable)*
Proof supplied (please state clearly what type of document you are relying upon).
Document Type: (Please state n/a if non applicable)
Relationship to Data Subject: (Please state n/a if non applicable)
Copy of Document:

Cancelof
PROOF MUST BE ENCLOSED THAT YOU ARE LEGALLY AUTHORISED TO OBTAIN THIS INFORMATION.

By completing this form, you are making a request under the General Data Protection Regulation (GDPR) for information held about you by the organisation that you are eligible to receive. Alternatively, if the Data Subject is deceased, the Access to Health Records Act 1990 will apply.
PLEASE SPECIFY WHAT INFORMATION IS BEING REQUESTED (AND ANY RELEVANT DATES): (Please state n/a if non applicable)*
Example: Emails between "A" and "B" from 1 May 2024 to 6 September 2024 (please be as specific as possible to enable us to process your request in a timely manner).Please note that requests that are manifestly unfounded or excessive will be rejected.
REASON WHY DATA IS REQUESTED: (Please state n/a if non applicable)*
By signing below, the individual named in this DSAR form indicates their identity. The Company cannot accept requests regarding your personal data from anyone else, including family members unless they have authority to do so. Further identifying information may be required before responding to your request. The individual named in the form or appropriate representative warrants their identity and will fully indemnify us for all losses, cost and expenses if they are not.

Please return this form to our Data Protection Officer at the following address:

Paul Wright
DPO
Malhotra House
50 Grey Street
Newcastle upon Tyne
NE1 6AE

Or email to: paul@malhotragroup.co.uk

Please allow up to one month for your request to be processed.
SIGNATURE:*

Clear
FULL NAME (IN CAPITALS):*

First NameLast Name
DATE:*

MonthDayYear
Date
Should be Empty:

DATA SUBJECT ACCESS REQUEST (DSAR) FORM

DATA SUBJECT'S DETAILS

DETAILS OF PERSON REQUESTING THE INFORMATION (IF NOT THE DATA SUBJECT).IF YOU ARE THE DATA SUBJECT I.E. THE PERSON REQUESTING THE INFORMATION ON YOUR OWN BEHALF, YOU DO NOT NEED TO COMPLETE THE SECTION BELOW:

Proof supplied (please state clearly what type of document you are relying upon).

PROOF MUST BE ENCLOSED THAT YOU ARE LEGALLY AUTHORISED TO OBTAIN THIS INFORMATION.