AUTHORIZATION FOR ACCESS, Disclosure, and processing

OF PERSONAL DATA

I, the undersigned,

First Name Click or tap here to enter text.	Family Name Click or tap here to enter text.
Father’s Name Click or tap here to enter text.	Mother’s Name Click or tap here to enter text.
Date of Birth Click or tap here to enter text.	Place of Birth Click or tap here to enter text.
Country of origin Click or tap here to enter text.	Nationality (if different from country of origin) Click or tap here to enter text.
Reference number Aliens Office Click or tap here to enter text.	Reference number CGRS Click or tap here to enter text.
If available, reference number(s) in third country (ies) (also mention third country) Click or tap here to enter text.

hereby authorize UNHCR to have full access, directly or indirectly, to personal data, documents, and any other relevant information pertaining to my asylum application / stay in Belgium or any other country in order to assist in my asylum or family reunification procedure or for the specific purpose described below:

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Such personal data may notably include: name, age, gender, nationality or country of origin, mains reasons for fleeing, residence status, flight journey, handling of my international protection / residence procedure in Belgium, family situation, studies and training, professional experience and occupation, sexual orientation, political opinions, spiritual orientation, personal experiences in Belgium and other countries regarding contact with administrations or service provides.

I also authorize UNHCR to transfer such information to its implementing partners in Belgium, Myria and Nansen asbl, or to make use of such information in its discussions with other third parties, including government officials of any country with the exception of my country of origin, and exclusively for the purposes described above.

I understand that the fact that UNHCR collects data does not automatically imply that UNHCR will intervene in my case.

I understand that it is important to provide accurate and complete information.

I understand that all information provided to UNHCR will be kept confidential and that any processing and transfer of my personal data will be strictly regulated by UNHCR based on its Data Protection Policy (https://www.refworld.org/docid/55643c1d4.html) and that measures will be taken to safeguard the data and prevent unauthorized dissemination or access.

I am aware that I can raise concerns about UNHCR’s collection, accuracy, and use of my data, and that I can make complaints concerning this, either to UNHCR Office in Brussels (https://www.unhcr.org/be/contact) or, in confidence, to the Inspector General’s Office in UNHCR Headquarters (https://www.unhcr.org/making-complaint.html).

Date & Place	Signature & Print Name
This document has been translated to me in ________________________________________________

FOR LEGAL GUARDIANS:

In the case that the applicant is under 18 years of age, or otherwise unable to provide informed consent, and is accompanied by a legally appointed guardian:

I, confirm that I have explained and counselled the applicant on the content of this consent form to the extent possible, considering his/her age and level of maturity, and that I have taken into consideration his/her best and vital interests.

I authorize UNHCR to access and transfer information about the child [and his/her family members] as described above.

Date & Place	Name of Legal Guardian & Signature

FOR UNHCR STAFF:

In the case that the applicant cannot read English, or where the applicant is under 18 years of age and does not have a legally appointed guardian:

I confirm that I have explained and counselled the applicant on the content of this consent form in a language s/he can understand and in a manner that is appropriate to his/her age and maturity (either directly or through the assistance of an interpreter) and that s/he has been given an opportunity to ask questions that were responded to before obtaining his/her fingerprint/signature.

Date & Place	Name of Staff (Title) & Signature

Declaration on representative(S)

I, the undersigned, hereby certify that, [name of representatives]

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acts on my behalf in matters related to my: [choose as relevant]

☐	asylum claim

☐	family reunification request

☐	other: [describe]

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and is authorised to access any data on my case.

Date & Place	Signature & Print Name
This document has been translated to me in ________________________________________________

UNHCR services are always free of charge.

UNHCR has a zero tolerance policy

regarding sexual exploitation and abuse against the people it serves.