FOI Request

Clerk's Department
1155 Emily Street, Mooretown, ON N0N 1M0

Telephone: 519-867-2021
FREEDOM OF INFORMATION REQUEST FORM
Please note, a $5.00 application fee is required for all requests.

Additional fees may be charged in accordance with the Municipal Freedom of Information and Protection of Privacy Act and/or the Personal Health Information Protection Act.
Name of Department request made to:*
Information*

Access to General RecordsAccess to Own Personal InformationCorrection to Own Personal
Name*

First NameLast Name
Middle Name
Address*
City/Town*
Province*
Postal Code*
Telephone*
Email Address*
example@example.com
If request is for access to, or correction of, own personal information records:
Last name appearing on records*
Please provide a detailed description of requested records, personal information or personal information to be corrected.*
Please specify a record date range, if known: Date from:

MonthDayYear
Date
To:

MonthDayYear
Date
Please Note:
- If you are requesting access to or correction of your personal information, please identify the personal information bank or record containing the personal information, if known.
- If you are requesting a correction of personal information, please indicate the desired correction and, if appropriate, attach any supporting documentation. You will be notified if the correction is not made and you may require that a statement of disagreement be attached to your personal information.
- If you are requesting personal information for yourself or for a third party with consent, you will be required to provide a copy of government-issued identification prior to records disclosure (i.e. driver's license, Ontario photo card, passport, etc
Preferred method of records access:*

Examine OriginalReceive Electronic Copy, by emailReceive Paper Copy, by mail (additional fees apply)Receive Electronic Copy, by mail (additional fees apply)
Date:*

MonthDayYear
Date
Signature*

Clear
How will you be paying the 5$ Application fee?*

In Person by Cash/Debit at 1155 Emily St. MooretownBy Cheque, Mailed to 1155 Emily St. Mooretown, ON, N0N 1M0
Personal information contained on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act R.S.O. 1990, CHAPTER M.56 and/or the Personal Health Information Protection Act R.S.O. 2004 CHAPTER 3, SCHEDULE A and will be used for the purpose of responding to your request. Questions about this collection should be directed to the FOI Coordinator at 519-867-2021 x 1241.
Should be Empty:

Clerk's Department

FREEDOM OF INFORMATION REQUEST FORM

Please Note: