Data Protection Act 1998 Subject Access Request Application – 1939 Register Application This form is to be used if you wish to find out what information, if any, The NHS Information Centre is holding or is processing that relates to you. Please return your completed application form to: Information Governance Department The NHS Information Centre for Health and Social Care 1 Trevelyan Square Boar Lane Leeds LS1 6AE 1 Section 1: About Yourself Title: Surname: First Name: Former Surname: Date of Birth: Sex (Male/Female): NHS Number (if known) Telephone Number (day): Email Address: Home Address: Postcode: If you would have been known to us by a different name or at a different address during the period to which the information you are seeking relates, please state the name(s) and address (es) below: Name: From (date): To (date): From (date): To (date): Address: Postcode Name: Address: 2 Postcode Section 2: Proof of Identity To help establish your identity, you must submit a photocopy of one document from each of the following categories with your application. i. Confirmation of name1 ii. Full driving licence Passport Birth certificate Marriage certificate NHS Information Centre identity badge Confirmation of address Utility bill Bank statement Credit card statement Benefit book Pension book I am providing the following types of identification, which are attached to this document. i. Confirmation of name ii. Confirmation of address 1 Where you have had a change of name we will require evidence of the name for which you are seeking information e.g. a birth certificate will not be considered as evidence for searches on a married name. 3 Section 3: Helping us to find the information Please use to space below to provide further details that may help to locate the information you are seeking, such as: Full name Address as at 29th September 1939 (if known) DOB Registration number etc Section 4: Declaration The information that I have supplied in this application is correct, and I am the person to whom it relates. For Power of Attorney please ensure you attach copies of relevant authority. Signature: Date: Your Checklist Is your contact information correct? Have you enclosed acceptable identification? Have you signed the form? Have you completed all the sections? 4