GDPR Consent Form Template

FOR USE WHEN COLLECTING PERSONAL DATA IN/FROM EUROPEAN UNION

Required by European Union General Data Protection Regulation 2016/679 (“EUGDPR”)

To Be Signed By Individual Providing Personal Data

Montclair State University is the controller of your personal data.  You may contact Montclair State University at 1 Normal Avenue, Montclair, NJ 07043 or by phone and email at: [Insert Name and Contact Info of Person in Unit Requesting Personal Data].

Your personal data will be used for the following purposes (check all that apply):

___ marketing academic programs;
___ communicating University activities and accomplishments;
___ soliciting donations;
___ recruiting students;
___ recruiting employees;
___ research;
___ Other [include detailed description of use of personal data].

The categories of personal data you are being asked to consent to the University’s collection and use are your name, address, email address, telephone number and [include description of any other personal data collected].

The University will share your personal data with third party software providers who collect, store and process your personal data on behalf of the University and who are contractually obligated to keep your personal data confidential subject to appropriate safeguards to prevent it from unauthorized disclosure.  The University also intends to share your personal data with:  [identify all University units and third parties that will receive personal data].

Your personal data will be transferred out of the European Union to Montclair State University located in the United States.

Your personal data will be stored in accordance with the record retention requirements applicable to Montclair State University as a public research institution of New Jersey, and any other applicable U.S. laws.  Under the EUGDPR, you have the right to request access to, rectify, erase and restrict the processing of your personal data.  You also have the right to revoke this consent to use your personal data.  If you feel the University has violated the EUGDPR, you have the right to file a complaint with the appropriate EU supervisory authority.  These rights are more specifically described in the Privacy Notices posted on the University website at www.01001111.net.

Please [sign/electronically sign/check box below], date and return by [email/submit] the below:

I consent to Montclair State University using my personal data for the purposes described in this notice and understand that I can withdraw my consent at any time.

___ gives consent                    ___ does not give consent

Name of Individual providing Consent: _______________________________________________________

Address of Individual providing Consent: ______________________________________________________

Signature: ______________________________________________________________________________

Date of Signature:______________________________________________________________