BENEFICIARY FORM - ANTIGEN TEST KITS AND MASKS RECIEVING
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PLEASE FILL IN THE FOLLOWING DETAILS
Privacy Act and Personal Information Protection and Electronic Documents Act:
We are collecting information for the project in compliance with the Privacy Act, and the Personal Information Protection and Electronic Documents Act. The data collected is strictly to help us create programs for the community and not for third party. Hence, anyone in the team is required to comply with the same.
Do You Agree With The Above Act? *
Required
DATE Y/M/D *
NAME *
PHONE NUMBER *
RESIDENTIAL ADDRESS POSTAL CODE *
PLEASE HELP US KNOW THE TOTAL NUMBER OF HOUSEHOLD INCLUDING CHILDREN *
PLEASE PUT A CHECK ON WHAT DEFINES YOUR HOUSEHOLD *
Required
PLEASE STATE THE NUMBER OF ANTIGEN TEST KITS YOU RECEIVED *
PLEASE STATE THE NUMBER OF MASKS YOU RECEIVED *
PLEASE NAME THE COMMUNITY AND/OR ORGANIZATION HELPING YOU *
COMMENTS (Advice/Concern/Feedbacks)
Do you wish to stay updated on future reach out for COVID and other community-oriented programs? *
Use and Availability of COVID-19 Screening Tests and Masks.
If COVID-19 Screening Tests and masks are provided by the GAC to individuals, then the individuals will only use the COVID-19 Screening Tests in Canada (and will not be exported or used elsewhere). The individuals will not utilize the COVID-19 Screening Tests or masks for purposes outside of the Permitted Purposes or sell or otherwise assign or dispose of the COVID-19 Screening Tests or masks without the consent of the GAC in writing at admin@theglobalalliancecanada.org
THANK YOU!
FOR QUESTIONS AND CONCERNS PLEASE EMAIL US ON admin@theglobalalliancecanada.org
A copy of your responses will be emailed to the address you provided.
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