Privacy Consent Form

I, ________________________, do hereby acknowledge that I have read, understood, and agreed to

MSI’s Data Privacy Notice (the “Notice”), and do hereby voluntarily give my consent to the collection,
use, disclosure, sharing, retention, and processing of my personal information under such terms and
conditions set out in the Notice.

I also acknowledge and warrant that I have acquired the consent from all parties relevant to this consent
and hold free and harmless and indemnify MSI from any complaint, suit, claim, or damage which any
party may file in relation to my consent.

Furthermore, I understand that the consent I am giving through this form shall remain in full force and
effect until I revoke it in writing.

Signed this _____ day of __________, 20___ at _____________________.

Signature: ________________________

Name: ________________________

IF INDIVIDUAL IS A MINOR OR INCAPABLE TO GIVE CONSENT

________________________________ _______________ __________

Legal Representative Relationship to Applicant Date
(Signature above Printed Name) (MM/DD/YY)

Reason why Individual cannot accomplish form

(Paalala: Tawagin ang pansin ng klerk o empleyado ng MSI kung hindi nakakaunawa ng Ingles)

MLA-FRM-DPA-01 Rev No: 00 , Rev Date: 01/03/2019 Page 1 of 1

Revision Date Revision Number Approved by Details of Change
01/03/2019 00 DPO MSI First Issue