Authorisation Form to allow other nominated contact(s) to act on behalf of DAFM clients

• Published date: 01 October 2019

Authorisation Form to allow other nominated contact(s) to act on behalf of DAFM clients DAFM Auth 4

for all DAFM related queries

An Roinn Talhaíochta, Bia agus Mara, Oifigí Rialtais, Sráid Fhearnáin, An Cabhán H12 D459 │ Department of Agriculture, Food and the Marine, Government Buildings, Farnham Street, Cavan, H12 D459

Panel A – Customer details

To be completed and signed by the Client(s). This form must be completed by all

those registered to a Department identification number e.g. Herdnumber, Forest

Owner number etc. If the Department identifier is registered to more than one

individual, then all interested parties must sign this form. Provision has been made

for up to 3 interested parties below.

Please use BLOCK CAPITALS.

Name(s): ___________________________________________________________

(as registered with the Department of Agriculture, Food and the Marine)

Address: ___________________________________________________________

___________________________________________________________________

Telephone No: _____________________ Mobile No: __________________ _____

Do you wish to receive text messages in relation to your business with the Department, including

information on scheme deadlines, payments and other alerts. Yes No

Department Identifier _____________________________

(e.g. Herd number, Forest Owner number, Registered Farm Partnership Number etc.)

Liability, Indemnity, Authorisation and Declaration.

The Department of Agriculture, Food and the Marine shall not be liable for any direct or i ndirect loss

or liability to the client resulting from the actions of the nominated contact(s) in respect of the clients

personal matters or personal data. Full responsibility for the actions of the nominated contacts rests

with the individual concerned. The Department reserves the right to withdraw this service from an

individual where there is evidence of improper use of the service.

I/We confirm that the information in this Panel A is correct to the best of my/our knowledge and that

it refers to me/us.

I/We further confirm that I am/we are the registered interested parties of the Department identifier

mentioned above. I/We authorise the Department of Agriculture, Food and the Marine to forward

my/our personal details/data to the nominees at Panel B.

I/We understand that all data held/requested/accessed by the Department is subject to Data

Protection Legislation.

Signed: ________________________________ Date: ________________

Signed: ________________________________ Date: ________________

Signed: ________________________________ Date: ________________

I/we wish to have the nominated contact(s) in respect of whom details are supplied in Panel

B below, to act on my/our behalf in personal matters including access to personal data, with

the Department of Agriculture, Food and the Marine.

This form, when completed, should be emailed to CCSAdmin@agriculture.gov.ie or sent to

the following address:

Department of Agriculture, Food and the Marine (CCS),

Government Buildings,

Farnham Street,

Cavan,

H12 D459

Panel B – Nominated Contact’s details

To be completed in respect of the nominated contact and to be signed by the

nominated contact. Please use BLOCK CAPITALS.

The personal data sought from you, the nominated contact is required to enable you act

on behalf of the client(s) in relation to personal matters, including access to personal

data, arising with the Department of Agriculture, Food and the Marine. Failure to

provide all the personal data required will result in DAFM being unable to authorise you

to act on behalf of the client(s).

Name of nominated contact 1: ____________________________________________

Organisation Name or relationship to client: ________________________________

Signed: ________________________________ Date: ______________

______________________________________________________________________

Name of nominated contact 2: ____________________________________________

Organisation Name or relationship to client: _______________________________

Signed: ________________________________ Date: ______________

______________________________________________________________________

Name of nominated contact 3: ____________________________________________

Organisation Name or relationship to client: _______________________________

Signed: ________________________________ Date: ______________

______________________________________________________________________

Name of nominated contact 4: ____________________________________________

Organisation Name or relationship to client: _______________________________

Signed: ________________________________ Date: ______________