HTML version of the form: Record Correction Request Form (Privacy Act)
Use this form to request corrections of the content of your information if you believe there areerrors or omissions. Documentary proof may be requested before the corrections are effected.Only one request per form. Please print clearly.
Reference No.:
For Official Use Only
- Office address:
- Receiving officer:
- Date:
Access Information
- Federal government institution:
- Information bank no.:
- Information bank title:
- Other detail(s) specified in Info Source for this bank:
Personal Information
- Surname:
- Given names:
- Address:
- City:
- Province:
- Postal code:
- Tel. no. (Home):
- Tel. no. (Work):
- Surname in bank if different from above:
- Other personal information specified in Info Source:
I Wish To Make The Following Correction(s)
Note: If the space below is inadequate continue on the back of this form.
- Identification of record(s) or items concerned:
- Correction(s) requested:
If this request follows a previous inquiry, please quote reference number here:
Please quote this reference number on all correspondence.
Signature:
Date:
When you have completed this form, send it to the official identified in Info Source for this bank.
TBC/CTC 350-11 (Rev. 1993/02)