FOR OFFICE USE ONLY
StarRez ID: _______________
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LANDLORD REFERENCE FORM
Informed Consent for Disclosure of Personal Information
MacEwan University collects and protects personal information under the authority of the Alberta Freedom of Information and
Protection of Privacy Act for the purposes of operating the programs and services of the University.
If you require the disclosure of your personal information to another person, designated agent or agency, legal counsel or for other
purposes, please complete the following informed consent document as required under the Act.
Submit this form to Residence Services via email to [email protected].
Personal Information
Last Name
First Name
Room # (former or current)
Email
Phone
Consent to Release Information
I voluntarily authorize Residence Services, MacEwan University
to disclose information regarding my tenancy in residence at MacEwan University.
Information includes, but is not limited to, payment history, incident
reports, cleaning charges, damage charges and vandalism charges
originally collected to administer student housing
releasing to potential new landlords
for the purpose of providing residence references
for the period ________________________ to _________________________
DD/MM/YYYY DD/MM/YYYY
Date range for which permission will exist
Important Notes
Consent may be revoked at any time by indicating in writing to the Residence Services Office.
Protection of Privacy - The personal information requested on this form is collected under the authority of Section 33(c) of the Alberta
Freedom of Information and Protection of Privacy Act. It will be used for the purposes of managing the consent for disclosure of the
personal information process.
Questions concerning the collection, use and disposal of this information should be directed to MacEwan Residence at
(780) 497-4500. The information will be retained and disposed of in accordance with approved record retention and disposal
schedules of the University.
Signature
By signing and submitting this form, I certify that I have read, understand and agree to the terms and conditions outlined on this form.
Signature
Date
DD/MM/YYYY
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