Personal Information Bank Registration (TBS 350-84)

PERSONAL INFORMATION BANK REGISTRATION

INSTITUTION

PART 1

Title of Personal Information Bank

PART 2

Programs related to this Personal Information Bank
Organizational Unit
Activity Related to program record(s) number

Public Archives of Canada (PAC) number

PART 3

a) Does this bank contain information gathered through either public opinion research or any other information collection project or activity?

No Yes

b) Number of individuals represented in the Personal Information Bank:

c) Does this bank contain personal information that is used for data matching purposes?

No Yes

If yes, with other federal government agencies - provide complete PIB number(s)

with other public sector organizations - specify

with private sector within Canada - specify

with organizations outside of Canada - specify

d) Is this bank an exempt bank?

No Yes

If yes, provide: Order in Council number Date

PART 4

Submitted by

Privacy Coordinator (please print) ________________________________________
Signature
Date

Bank entry complies with the provisions of section II (1) of the Privacy Act

TBS Official ________________________________________
Signature
Date

PART 5 FOR OFFICE USE ONLY

Personal Information Bank (check one of the following indicating the corresponding bank number)

Information on the General Public PPU

Information on Federal Employees PPE

Central Bank (employees) PCE

Standard Bank (employees) PSE

TBS Registration Sticker

TBS 350-84 (Rev. 1998/11) HTML Version 2000/12

PART 6

PLEASE PRINT THE CONTENTS OF THE PERSONAL INFORMATION BANK - AS IT WILL APPEAR IN
INFO SOURCE
The following information is required:

· Description of the contents
· Class of individuals to whom the information relates
· Purpose of the bank
· Consistent uses, including disclosure, linking and matching
· Retention and disposal standards

Please note: Instructions related to this form and to the information which must be included in a Personal Information Bank are available from your Portfolio Officer at Treasury Board Secretariat.

You may attach additional pages if required. Please indicate the number of pages:

Programs related to this Personal Information Bank Organizational Unit Activity	Related to program record(s) number
	Public Archives of Canada (PAC) number

PLEASE PRINT THE CONTENTS OF THE PERSONAL INFORMATION BANK - AS IT WILL APPEAR IN INFO SOURCE The following information is required:
· Description of the contents · Class of individuals to whom the information relates	· Purpose of the bank · Consistent uses, including disclosure, linking and matching	· Retention and disposal standards
Please note: Instructions related to this form and to the information which must be included in a Personal Information Bank are available from your Portfolio Officer at Treasury Board Secretariat.

You may attach additional pages if required. Please indicate the number of pages: