PIPEDA Form

The Personal Information Protection and Electronic Documents Act (PIPEDA) Permission Form for publishing information on the CVU Household Directory AND realizing that this information will be shared with the Canadian Unitarian Council (CUC) www.cuc.ca

Download PDF if you would rather print out the form, fill in on paper and bring in to our ADMIN
Date:
MM slash DD slash YYYY
Name:
First Last
Pronouns
Partners Name:
First Last
Children's Names and Birthdays:
Name Birthday
May we list the names on the Household list?
- Yes
- No
Address
Street Address Address Line 2 City Province Postal Code
Mailing Address:
If different from your home address.

Street Address Address Line 2 City Province Postal Code
May we list the address(es) on the Fellowship list?
- Yes
- No
Phone number/s
May we list this phone number on the Household list?
- Yes
- No
Emaill/s
May we list this email on the Household list?
- Yes
- No
Would you like PAD information?
PAD = preauthorized donation forms
- Yes
- No

Comox Valley Unitarian Fellowship

PIPEDA Form

Related

Comox Valley Unitarians

250 Beach Drive, Comox, B.C. V9M 1P9

admin@cvuf.ca

website@cvuf.ca

Name	Birthday