Form Gs 121 Canada – Fill Out and Use This PDF

Authorization of Representative

I,							,
living at					, in the province of		,
authorize
living at					, in the province of		,
as my personal representative to act on my behalf, and to exercise:
(select one)

all my rights under the Freedom of Information and Protection of Privacy Act

my right to access all my records containing personal information in all categories of personal information

my right to access all of the following records containing personal information or all of the following categories of personal information (number and titles of records or categories):

the rights that I have under the Freedom of Information and Protection of Privacy Act regarding the following other matters (e.g. consent to disclose personal information):

I confirm that my representative has the authority to exercise the above right(s) under the Act for me.

This authorization will be in effect until

Signed By		in the presence of
	Signature of Authorizing Person		Signature of Witness
			(See Affidavit of Witness form to complete)

GS 121 (2001/12)

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Affidavit of Witness

CANADA

IN THE PROVINCE OF ALBERTA

I,				,
				Name of the Witness in Full
				,
				Occupation of Witness
of				,
				Complete Home Address of Witness
in the province of								, make oath and say that:
1. I was personally present and I saw
							Name of Individual
	sign the Authorization of Representative form to which this is attached.
2. The Authorization of Representative form was signed by
								Name of Individual
	at					, in the province of

and that I am the one who witnessed the form.

Signature of Witness

Sworn before me at in the province of on

Commissioner for Oaths

Print Name

Expiry Date of Commission

GS 121 (2001/12)

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