Authorization

for Disclosure of Personal Information to a Third Party

This form is intended only for prospective students requesting assistance in their application to The
University of British Columbia (UBC) via a third-party organization, such as an educational agency or
consultancy.

HA THAI SON
I, _______________________________________________, authorize UBC to disclose my
(Current Legal Name – Please Print)
personal information to:

NGUYEN THI ANH KHUE VICE DIRECTOR

_____________________________________ ______________________________________
(Name of Third Party) (Title or Position)

VIETNAM CENTRE POINT JSC 842838337747

_____________________________________ ______________________________________
(Organization or Company) (Phone/Cell)
I authorize UBC to disclose the following information for the purpose of facilitating my application,
admission and registration as a student at UBC:
• Details regarding my admission status and the results of my application to UBC. This includes
information such as my UBC ID1 number, academic information including transcripts or English
proficiency documentation;
• Any communications required to facilitate my online application, as well as my admission and
registration as a student at UBC and my on-campus housing status (if applicable);
• Financial information regarding my application, tuition, on-campus housing (if applicable) and
student fees and the status of my account.

This consent becomes effective from the following date: ___________________________________

(DD/MM/YY)
This consent will end if I am denied admission to UBC, withdraw my application to UBC, or upon my
written request, whichever occurs earliest. However, I understand if I am admitted to UBC and enroll in
courses, this consent will end one year after I begin my UBC studies.

Signature: _________________________________ Date: ________________________________

23/02/2005
*Date of Birth: _____________________________ *Day Phone: __________________________

sonthaiha07@gmail.com
*Email Address: ____________________________

*This information must be included. The email address and date of birth are needed to confirm your
identity. We may also need to phone you for the same purpose or for related enquiries.
1
The UBC ID number will not be generated until students apply to UBC.

Authorizations should be sent to: International Student Initiative – Strategic Partnerships

The University of British Columbia
1200-1874 East Mall, Vancouver, BC V6T 1Z1 Canada
Fax: +1-604-822-9888 recruit.intl@ubc.ca