INDIVIDUAL'S CONSENT TO DISCLOSURE OF PERSONAL INFORMATION I, , Date of Birth: _____ (name of individual) residing at: _____ , Telephone no: (full address) do hereby authorize WorkSafeBC (the Workers' Compensation Board of BC) to disclose my personal information from the following records: (identify records) to: (specify name and address of the body or person authorized to receive and/or use this information) to be used only for the purpose of: _____ This consent shall be and remain in effect for 2 years unless otherwise specified or revoked in writing prior to that date. (signature of individual giving consent) (date) For further information about the collection of personal information please contact WorkSafeBC’s Freedom of Information Coordinator.