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Act to protect my personal information. Signed at B.C. on in the presence of City Signature of Witness Name and address of Witness Date Signature of Student If the student has any questions regarding how his or her personal information will be used by ICBC he or she may contact Driver Testing Vehicle Information Services 151 West Esplanade North Vancouver BC V7M 3H9 Telephone 604 661-2255 Toll Free 1-888-715-7775 DTC205 042008. Road Test Booking Service Student Consent and Release Prior to a Driver Training School booking a road test on behalf of a student the student must provide his or her consent for the school to book a road test on the student s behalf and disclose personal information about that student to ICBC for the purpose of booking a road test. The completed form must be kept in the student record. I authorize Name of Student Name of Driver Training School to book road tests on my behalf and disclose the following personal information to the Insurance Corporation of British Columbia ICBC for the purpose of booking a road test in accordance with sections 26 and 27 of the Freedom of Information and Protection of Privacy Act the Act My name My learner s licence number My e-mail address if applicable My contact phone number 1. I understand that if I fail to attend a road test appointment booked on my behalf without providing either at least 48 hours notice of cancellation to ICBC or a reason for my failure to attend that is satisfactory to ICBC I will be charged a 25. 00 fee for each missed test at my next road test appointment. This 25. 00 fee is in addition to the usual road test fees. 2. I understand and agree that ICBC may use the above information to update its customer database and that ICBC will not disclose the above personal information to any external third party without my consent except where authorized by law or for law enforcement purposes. Road Test Booking Service Student Consent and Release Prior to a Driver Training School booking a road test on behalf of a student the student must provide his or her consent for the school to book a road test on the student s behalf and disclose personal information about that student to ICBC for the purpose of booking a road test. The completed form must be kept in the student record. I authorize Name of Student Name of Driver Training School to book road tests on my behalf and disclose the following personal information to the Insurance Corporation of British Columbia ICBC for the purpose of booking a road test in accordance with sections 26 and 27 of the Freedom of Information and Protection of Privacy Act the Act My name My learner s licence number My e-mail address if applicable My contact phone number 1. The completed form must be kept in the student record. I authorize Name of Student Name of Driver Training School to book road tests on my behalf and disclose the following personal information to the Insurance Corporation of British Columbia ICBC for the purpose of booking a road test in accordance with sections 26 and 27 of the Freedom of Information and Protection of Privacy Act the Act My name My learner s licence number My e-mail address if applicable My contact phone number 1. I understand that if I fail to attend a road test appointment booked on my behalf without providing either at least 48 hours notice of cancellation to ICBC or a reason for my failure to attend that is satisfactory to ICBC I will be charged a 25.

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