INTERNATIONAL STUDENT ADMISSIONS

1750 Finch Ave. East Toronto, Ontario M2J 2X5 CANADA

Tel: 416.491.5050 x.2364 Fax: 416.492.9243

Student Information Release Form

PLEASE PRINT CLEARLY
Male Female

I,
Student First Name Student Last Name

Address City

Country Postal Code

Telephone E-mail

Date of Birth (Month / Day / Year) Seneca College Student ID Number

hereby authorize

my Agent Male Female other Male Female

Agent First Name Agent Last name First Name Last name

Company Name Address

Address City Country Postal Code

City Country Postal Code Telephone

Telephone E-mail

E-mail Relationship to Student

Agent Number

to act on my behalf in all matters concerning my application for admission to Seneca. Seneca College is subject to the
provisions contained within the Province of Ontario’s Freedom of Information and Protection of Privacy Act. As such, Seneca
College has the obligation to inform you about the collection and use of your personal information. By completing this
Student Information Release Form, you are authorizing Seneca College to release your personal information to the
person(s) you have authorized to act on your behalf concerning your application for admission to Seneca College,
including, if necessary all international admission matters. Your signature on this form confirms your
acknowledgment and understanding of this notification. Seneca College assumes no responsibility or liability for the
use of your personal information by those you have authorized. For further information, email: agent.intl@senecac.on.ca

Date

Student Signature City, Country Revised Dec.06