(Date)

(Owner of material)

(Address)

Dear (Information Owner)

Permission to use and disclose material

I am in the process of completing an application for Chartered status with Engineers Australia. As part of my application I am required to provide evidence of my competency such as work samples.

It is my understanding that you/your organisation are the owner of the following material:

Description of the material – e.g., diagram/illustration/photograph (title or description of image, name of publication), etc.

I would like to provide this material to Engineers Australia as part of my application for Chartered Status.

All material provided as part of an application for Chartered Status will only be used by Engineers Australia and its representatives (including any third party assessors engaged by Engineers Australia to assess my application), strictly for the purposes of assessing the application (the Approved Purpose). Engineers Australia, on request, can securely destroy any confidential information contained in an application when it is no longer required for the Approved Purpose.

I would be most grateful for your consent to the use and disclosure of the material as proposed. If you are willing to grant this consent, please complete and sign the attached approval slip and return it to me at the address shown.

I look forward to hearing from you and thank you in advance for your consideration of my request.

Yours sincerely

(Name)

PERMISSION TO USE MATERIAL AS SPECIFIED BELOW:

[Specify material and source, as per cover letter]

I hereby give permission for [Insert name of applicant] to include the abovementioned material(s) in his/her application for Chartered status with Engineers Australia. This permission is granted on the following conditions:

The material will be used strictly for the purposes of assessing the application for Chartered status (Approved Purpose);

The material will not be disclosed to anyone other than Engineers Australia or its representatives (including any third party assessors engaged by Engineers Australia to conduct an assessment of the application);

The material will only be used for a period of time reasonably necessary for the assessment to be conducted and a final decision made by Engineers Australia on the application; and

Engineers Australia, on request, can securely destroy any confidential information contained in an application when it is no longer required for the Approved Purpose.

I confirm that I/my organisation are the owner of the specified material.

Signed:

Name:

Position:

Date:

Please return signed form to [Insert name and address of applicant]