Victorian Housing Register form of authority



0190500Victorian Housing Register form of authorityRelease of information to an external agencyWho can complete this form?This consent form is to authorise the Director of Housing, or officers acting on behalf of the Director of Housing, to confirm information concerning the application with the people and organisations I have nominated below:Name of primary applicantService IDDate of BirthAddressSuburb/TownPostcodeTelephone LandlineMobileEmail addressI hereby authorise the Director of Housing, or officers acting on behalf of the Director of Housing, to release my personal information to:Name of agencyAddress of agencyAgency contact personTelephone LandlineMobileEmail addressSignatureSignature of Primary applicant:(Please sign by hand)Date (DD/MM/YYYY):Declaration, acknowledgement and consentI declare that all the information I have provided in the Victorian Housing Register application is true and correct.I understand that as the primary applicant I have sole responsibility within my household to respond on all matters about my application.I acknowledge that I must advise the Department of Health and Human Services (the department) if my circumstances change and update the department with any details that are relevant to my application.I consent to the department to send copies of correspondence to the people and organisations I have nominated.WARNING if you wilfully give information that is untrue in this application, you may be liable to penalties under section 40 of the Housing Act 1983 (Vic).Information privacyThe Department of Health and Human Services is committed to protecting the privacy of your personal information. Housing applications are placed on the Victorian Housing Register where the Department of Health and Human Services and participating registered housing agencies will allocate housing from. All the information you give us will be handled in accordance with the Privacy and Data Protection Act 2014 and the Health Records Act 2001.If you are using other department programs, we may share some of your information with them to help us coordinate better services for you. We will not use your information for any other purpose other than those listed on these forms, to provide services to you, or without your consent, unless the law allows us to do so. We will take all reasonable steps to safeguard your information, from accidental loss, alteration or unauthorised access.You can access your information from the Register through the Freedom of Information Act 1982. For information about Freedom of Information requests, call 1300 650 172 or apply online at foi..auIf you are seeking information from a community housing organisation or designated service provider, then you have access rights under the Privacy and Data Protection Act 2014. For further information about privacy, call 1300 884 706 or email.privacy@dhhs..auTo receive this publication in an accessible format, email victorianhousingregister@dhhs..au or get it from our website at housing..au/forms-guidesISBN 978-1-76069-159-2 (pdf/online/MS word)Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.? State of Victoria, Department of Health and Human Services, January 2020Available on the Forms and guides page of the Housing.vic website <; ................
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