[Your Name]
[Your Address]
[City, State, ZIP Code]
[Email Address]
[Phone Number]
[Date]
[Recipient’s Name]
[Recipient’s Position]
[Organization’s Name]
[Address]
[City, State, ZIP Code]
Subject: Written Consent for Use of Personal Data
Dear [Recipient’s Name],
I, [Your Name], residing at [Your Address], hereby give my written consent for the use of my personal data by [Organization’s Name] for the purpose of [specific purpose, e.g., research, marketing, enrollment].
The personal data to be used includes:
- Full name
- Address
- Contact information (phone number, email address)
- [Any other specific data, e.g., medical history, academic records, etc.]
I understand that this data will be used solely for the stated purpose and that [Organization’s Name] will take all necessary measures to protect my privacy and ensure the security of my personal information. The data will not be shared with any third parties without my explicit consent.
This consent is valid from [start date] to [end date]. I have the right to withdraw my consent at any time by providing written notice to [Organization’s Name].
If you require any additional information or have any questions, please feel free to contact me at [your phone number] or [your email address].
Thank you for your cooperation.
Sincerely,
[Your Name]
[Signature]