(Date)

To the Person in Charge of Access to Documents and
of Protection of Personal Information
Secrétariat général
Ministère de la Sécurité publique
2525, boul. Laurier, 5e étage
Tour des Laurentides 
Québec (Québec) G1V 2L2

Subject: Request for Access to Personal Information

Dear Sir,

	Pursuant to section 83 of the Act respecting Access to documents held by public bodies and the Protection of personal information, I would like to receive copies of document(s) containing my personal information:

Sincerely,

						Signature

						(Your contact information)
						(………………………)
						(…………….………...)
						(………..………….….)