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✂
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1
Please fill in the full name of the Data User to whom the data access request is addressed.
2
If you have previously been informed by the Data User of the name and/or job title of the person to whom such a data access
request may be made, please fill in here the name and/or job title of such person.
3
For Data Subject who is Hong Kong Identity Card holder. Please note that the information may assist the Data User to retrieve or
locate the Requested Data. The identity card number needs not be provided in this Form if you have reasonable grounds to
believe that this will not be necessary for the unique identification of the Data Subject by the Data User in the circumstances.
4
The Data User may require reasonably sufficient personal information from you to satisfy itself as to your identity before it can
comply with this data access request.
Part I:
Data User
Particulars of the Data User to whom this data access request is made
Name
1
(
full name in block letters
):
_________________________________________________________________________
_____________
_____
(for the attention of
2
___________________________________________________
)
Address:
_________________________________________________________________________
_________
_
_________________________________________________________________________
_____________
_____
Part II: Data Subject
Particulars of the Data Subject making this data access request
Name in English
(full name in block letters, surname first
):
________________________________________
Name in Chinese (if any):
_____________________________________________________________________
Personal identifier, e.g. Hong Kong Identity Card number
3
/ passport number or other
identification number previously assigned by the Data User (if any, such as student number,
staff number, patient number, account number, membership number or other reference
number):
___________________________________________________________________________________
Correspondence address:
______________________________________________________________________
_________________________________________________________________________
_____________
_____
Day time contact phone number:
_______________________________________________________________
Email address (if any):
________________________________________________________________________
[This part must be completed if this request is made by a Requestor other than the Data Subject]
Part III: The Requestor
Particulars and capacity of the Requestor
4
Name in English (
full name in block letters, surname first
):
________________________________________
Name in Chinese (if any):
_____________________________________________________________________
Correspondence address:
______________________________________________________________________
_________________________________________________________________________
_____________
_____
Day time contact phone number:
_______________________________________________________________
Email address (if any):
________________________________________________________________________
7
VIII: Furth Information and Payment
I understand that before complying with this request, you may require me to provide
12
:
(a) proof of my identity;
(b) proof of the Data Subject’s identity if I am making this request as a relevant person and further
proof of my status as a relevant person;
(c) such further information as may be reasonably required for you to locate the Requested Data;
(d) payment of a fee charged under section 28 of the PDPO
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.
Part IX:
Use of Personal Data
Except with the prescribed consent of the individual concerned, the personal data provided in this Form
will be used for the purpose of processing this data access request and other directly related purposes
only.
___________________________
___________________________________________
Date
Signature of the Requestor
12
ailure to provide t e nformation as requ red by t e Data User under this Part may esult in the data acc ss reque t being efused,
r not being complied wi h to the desired extent.
13
S ctions 28(2) and (3) of the PDPO pr vide that a fee may be charged for complying with a data ccess requ st made u d r section
18(1)( ) or (b), which fee shall not e excess ve. Acc rding t sec 28(5) of the PDPO, compliance with a da a access request
may be refused unless and until any such fee has been paid.
Form OPS003 (revised 09/2012)