Restriction of Consent

I wish to withdraw consent to use my personal information for the following purposes.

Please check all that apply.

	“To provide me with information, by direct mail, telephone or other means, on credit union products and services that you believe may be of interest to me. I understand you may not be able to provide some benefits, services or information which may be of value to me, but that you may continue to provide me with information on products and services with my account statements and in your newsletters”.
	“To provide me with information on the products and services of your affiliates and service suppliers that you believe may be of interest to me. I understand I may not receive information on the products or services of your affiliates or service suppliers which may be of value to me”.
	“To use my Social Insurance Number for credit matching purposes. This will not affect the provision of any credit union services to me”.

I understand that I can change my mind on these choices at any time.

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Signature

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Name (please print)

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Address

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Telephone Number

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Account Number(s)