FREE POPIA TOOLKIT

SUPPORTING TEMPLATE

Consent Withdrawal Form

1. Personal Information

• Full Name: [Insert Full Name]
• Contact Information: [Insert Contact Information]
• Identification Number (ID)/Passport Number: [Insert ID/Passport Number]
• Date of Birth: [Insert Date of Birth]
• Address: [Insert Address]
• Email Address: [Insert Email Address]
• Phone Number: [Insert Phone Number]

2. Consent Withdrawal

I hereby withdraw my consent for [Organization Name] to process my personal information for the purposes specified in the Consent Form dated [Insert Date of Consent Form].

3. Reason for Withdrawal

Please provide a brief explanation for withdrawing your consent:

[Insert Reason for Withdrawal]

4. Contact Information

If you have any questions or concerns regarding the withdrawal of your consent or the processing of your personal information, please contact us at:

[Insert Contact Information]

5. Signature

By signing below, I acknowledge that I have read and understood the contents of this Consent Withdrawal Form and confirm my withdrawal of consent for the processing of my personal information by [Organization Name].

Signature: ________________________________

Date: ________________________________

This Consent Withdrawal Form should be used by individuals who wish to withdraw their previously given consent for the processing of their personal information by the organization. It provides a structured format for individuals to indicate their withdrawal of consent, provide a reason for the withdrawal if desired, and includes contact information for inquiries or concerns.