Consent for Veterans Affairs Canada Disclosure
Provide your consent to disclose personal information to third parties. Ensure all required fields are completed.
Client Identification
CSDN ID
File No.
Last name
*
First name
*
Middle name(s)
Date of birth (yyyy-mm-dd)
*
-
Month
-
Day
Year
Date
Service No.(s)/RCMP Regimental No.(s)
Third Party to Whom VAC May Disclose Information
Name (last name, first name) OR Name of organization
Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mailing address
*
City/Town/Village
*
Country
*
Please Select
Canada
United States
United Kingdom
Australia
France
Germany
Italy
India
China
Japan
Mexico
Brazil
South Africa
Other
Province/Territory/State
Postal Code/ZIP
*
Information Authorized for Disclosure
Information authorized for disclosure
*
All information held by VAC
The following information only
Specify the information
Declaration and Consent
Signature
*
Date (yyyy-mm-dd)
*
-
Month
-
Day
Year
Date
Submit
Submit
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