Appendix 3 - Consent to release information

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I, (name of the applicant), consent that (name of the specialist) release information on my condition to (person and organization name). This information will be used for the express purpose of determining appropriate accommodations for examinations, tests, interviews and other exercises part of the assessment component of the appointment process in the Public Service of Canada for which I applied.

Applicant name (please print):

Telephone number:

Date (dd-mm-yyyy):

Signature:

Applicant date of birth:

(Note that the date of birth is usually required by the specialist office, in order to retrieved the specific file of the person)

Specialist phone number:

Specialist fax number:

Specialist address:

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