CONSENT TO COLLECTION, RETENTION AND USE OF

PUBLISHED INFORMATION AND PERSONAL INFORMATION

I hereby acknowledge that I have had an opportunity to review the document titled Privacy Policy of the Canadian Register of Health Service Providers in Psychology. I hereby consent to the collection, retention and use of all information pertaining to me held by the Canadian Register of Health Service Providers in psychology in accordance with this privacy policy.

Signed: ____________________________________________

Date: ______________________________