Freedom of Information Request Form
Time Elapsed:
0
minutes
Time Remaining:
0
minutes
Total Time:
0
minutes
Anonymous Login Code:
Save this code, which is required to update your response at a later time.
Page 1 of 1
Please Note:
A $5.00 application fee is required for all requests.
1.
Request For:
*
Access to General Records
Access to Own Personal Information
Correction to Own Personal Information
Please indicate if the last name appearing on the records is the same as below. If not, please indicate the full name on the record.
2.
Name of Institution Request Made to:
*
--Please Select--
County of Essex
Essex-Windsor Emergency Medical Services
Sun Parlor Home
Essex County Library
Essex-Windsor Solid Waste Authority
3.
Contact Information:
*
--Please Select--
Mr.
Mrs.
Ms.
Miss
4.
Last Name:
*
5.
First Name:
*
6.
Middle Name:
*
7.
Address (Street/Apt.No./PO Box/RR No.)
*
8.
City/Town:
*
9.
Province
*
10.
Postal Code
*
11.
Telephone Number (Day):
*
Indicate telephone number in the following format: XXX-XXX-XXXX
12.
Telephone Number (Evening):
*
Indicate telephone number in the following format: XXX-XXX-XXXX
13.
Email:
*
14.
Give a detailed description of requested records, personal information or personal information to be corrected. (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.)
Please Note:
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.
*
<p>Your browser does not support iframes.</p>
16.
Preferred Method of Access to Records:
*
Examine Original
Receive Copy
17.
I certify that the above information is correct.
*
Agree
Disagree
18.
Date:
*
Please click on the date that the form is being submitted.
yyyy/mm/dd
