FOI Request Form
February 2019
Freedom of Information (FOI) Request
(Accessible formats available upon request)
☐ Access to General Records ☐ Access to Own Personal Information
☐ Correction of Own Personal Information
Applicant Contact I nformation:
Name: _______________________________________________________________
Address: _____________________________________________________________
Town: __________________________ Province: _______ Postal Code:__________
Phone Number: __________________ Email: ______________________________
Detailed description of requested records, personal information records or personal
information to be corrected. Include additional sheets, if required.
Preferred method of access to records: ☐Paper ☐Electronic
Signature:_____________________________ Date: _________________________
Completed form must be submitted with $5.00 (payable to Town of Tillsonburg) to:
Clerk's Office, 519-688-3009
Corporate Office, 204-200 Broadway, Tillsonburg, ON, N4G 5A7
Personal information contained on this form is collected pursuant to the Municipal Freedom of
Information and Protection of Privacy Act (MFIPPA) and will be used for the purpose of
responding to your request. Questions about this collection should be directed to the Clerk's
Office at the institution where the request is made.
For Office Use Only:
Request Number: ________________ Date:______________________________