Required fields are marked with asterisks (*)

Personal Information Release Consent Form

Please contact the Clerk at 519-735-2184, ext. 116 if you have any questions.

First Name

Last Name

Street Address

City/Town

Province

Postal Code

Primary Contact Number

Secondary Phone Number

Email Address

Please provide specifics of what you are providing (e.g. picture of yourself and the reason why you are submitting the information)

This information may be released to the following: Town of Tecumseh for public distribution and promotion on its website, social media, and any other publication materials.

In accordance with the Municipal Freedom of Information and Protection of Privacy Act, as amended, I hereby consent to release the above personal information.

Are you 16 years old or younger?

Yes

First and Last Name of Contact Person at the Town of Tecumseh if known

Date of Submission

The personal information collected on this form is collected in accordance with the Municipal Freedom of Information and Protection of Privacy Act as amended and other legislation and will be used for the purpose of contact as stated above.

Forms

Personal Information Release Consent Form