Information of the Individual Submitting the Complaint Please circle one Mr. Mrs. Ms. Miss I am the Clients: (please circle one) Parent Legal Guardian Self (It is my client record) Surname Given Name Middle Name Address Unit City Province Postal Code Telephone Daytime Evening Email Address* * I, as the individual submitting the complaint, consent to being contacted at this email address or through the email address provided in this form. I acknowledge that sending personal information over the Internet is not secure as the email can be intercepted and/or manipulated and retransmitted. Details of the Complaint Please describe the details of the complaint:
Information of the Individual Submitting the Complaint Please circle one Mr. Mrs. Ms. Miss I am the Clients: (please circle one) Parent Legal Guardian Self (It is my client record) Surname Given Name Middle Name Address Unit City Province Postal Code Telephone Daytime Evening Email Address* * I, as the individual submitting the complaint, consent to being contacted at this email address or through the email address provided in this form. I acknowledge that sending personal information over the Internet is not secure as the email can be intercepted and/or manipulated and retransmitted. Details of the Complaint Please describe the details of the complaint:
APS_-_401_Privacy_Complaint_Form_v1.0.docx