Required fields are marked with asterisks (*)

Consent to Disclose Personal Information

The Municipality of Brighton is requesting written authorization by means of this form to disclose your personal information to a third party pursuant to section 32 (a) of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O., 1990. Please note that this consent is valid until it is revoked in writing.

Name

Property or Service Address

Roll Number

Water Account Number

Please describe in detail the information to be disclosed to the third party. Examples include address, details of arrears, account number, telephone number.

Name of Authorized Third Party

Third Party Address

Third Party Email

Third Party Telephone

Consent

By submitting this form, I understand that I am giving permission to an authorized staff person of the Municipality of Brighton to disclose my personal information to the third party specified above.