JavaScript is not enabled! Redirecting ... IMM5744E Consent Form
Input details, print and hand sign! Recommended
(DISPONIBLE EN FRANÇAIS - IMM 5744 F)
PROTECTED WHEN COMPLETED -
B
CONSENT FOR AN ACCESS TO INFORMATION AND
PERSONAL INFORMATION REQUEST
IMM 5744 (09-2018) E
If your spouse or common-law partner, children 16 years of age or older, or any other individuals whose information could be contained in the
requested records wishes to release their information to the designated representative, they must sign in the space provided. Information
about minors will only be released with the consent from both parents or a valid Canadian court order indicating that the applicant is
permitted to obtain their information. Obtaining consent from all parties will permit Immigration, Refugees and Citizenship Canada (IRCC) to
release their information and will provide you with more information in response to your request.
By signing this form, you authorize IRCC to release your information to the designated representative. Only original handwritten
signatures signed in blue ink will be accepted. Missing signatures may delay the processing of your request.
1. Designated Representative’s Information
Family name (surname)
Given name(s)
Firm/organization
Telephone number
Other telephone number
Address
City
Province/Territory
Country
Postal Code
Email Address
2. Applicant's Information
2.1 Related Individual’s Information
Family name (surname)
Given name(s)
Date of birth
(YYYY-MM-DD)
Signature (in blue ink)
Date (YYYY-MM-DD)
Family name (surname)
Given name(s)
Date of birth (YYYY-MM-DD)
Signature (in blue ink)
Date (YYYY-MM-DD)
Relationship to applicant
2.2 Related Individual’s Information
2.3 Related Individual’s Information
Family name (surname)
Given name(s)
Date of birth (YYYY-MM-DD)
Signature (in blue ink)
Date (YYYY-MM-DD)
Relationship to applicant
Family name (surname)
Given name(s)
Date of birth (YYYY-MM-DD)
Signature (in blue ink)
Date (YYYY-MM-DD)
Relationship to applicant
This consent is valid for one year from the date appearing next to the Applicant's signature.
The information provided is used to record consent for IRCC to disclose personal information to a designated representative in response to an ATIP request,
and is collected under the authority of section 6 of the Access to Information Act and sections 8(1) and 13 of the Privacy Act.
The requested information is required to validate your consent. Your information may be used internally to administer the ATIP request, and for planning and
evaluation purposes. This information may also be used during consultations with other government institutions, during investigations by the Office of the
Information Commissioner and the Office of the Privacy Commissioner, and during court reviews.
You have a right of access to, correction, and protection of personal information under the Act, and should you have any concerns with the management of
your personal information, you have a right to file a complaint to the Privacy Commissioner. The management of your information is described in the standard
personal information bank Access to Information Act and Privacy Act Requests (PSU 901) and can be found in
Info Source.