SYNECTICS SOLUTIONSDATA SUBJECT ACCESS REQUEST FORM
Please complete this form in full to request a copy of information we hold about you on thefraud prevention database operated by Synectics Solutions. This form may be rejected if you
fail to complete all relevant sections. Please note that Synectics Solutions can only share
records that match the details you have provided on this form.
An email address and contact number must be provided if you request to receive yourresults electronically.
Section 1: Your Details (use additional sheets where necessary)First Name

Middle NameSurname

Other Names (If applicable):(Other names you have been known by during the last
6 years e.g. maiden name. Proof of change must beprovided)

1.
2.
3.

Email addresses:

Telephone Number(s) used for the last 6 years:
1.
2.
3.

Mobile Number(s) used for the last 6 years:
1.
2.
3.

Date of Birth:
DDM

M

YY

Y

Y

Current Address:

Previous Addresses:(please provide your previous addresses for the last 6 years)

Address:

Address:

Synectics Classification: Confidential

Address:

Address:

Address:

Address:

V. SARREQLTR-8-0 (03-03-17)

Section 2: Proof of Identity
You must include TWO proofs of identity, one from list A and one from list B.
You should tick the appropriate box on each list to indicate which document you haveincluded.
List A: Enclose a CLEAR COPY of ONE of the following documents:
A valid signed passport including photograph
A valid UK photo-card driving licence (full or provisional) – both sides
A valid Biometric Residence Permit including Photocard (BRPs)
Recent evidence of entitlement to a state or local authority funded benefit (including
housing benefit and council tax benefit), tax credit, pension, educational or othergrant.
National Identity Card (non-UK nationals)
A valid (old style) Full Paper Driving Licence
Identity Card issued by the Electoral Office for Northern Ireland

List B: Enclose a CLEAR COPY of ONE of the following types of documents which must bedated within the last 12 months. It must show your name and current address:
N.B. We reserve the right to request original documentation
Current council tax demand letter or statement (Within the last year)
Utility bill for the supply of gas, electric, water or telephone landline
Current bank statement or credit/debit card statement issued by a regulated
financial sector firm in the UK, EU or equivalent jurisdiction)
Local Council Tenancy Agreement currently in force
HMRC or Department of Work and Pensions document
Document from Student Loans Company
Judicial document such as Notice of Hearing, Summons or Court Order
Most recent mortgage statement (Within the last year)

Synectics Classification: Confidential (when completed)

V.3.2

Important: Due to the rapidly changing situation relating to Coronavirus, we cannot
guarantee when we will receive and issue a response to applications sent via post. We
would ask that where possible, applications are sent via email to the below address to avoid
delays in receiving your results:
DSAR@synectics-solutions.com
Response to be issued by:
Post
EmailPlease confirm the email address you would like your results to be issued to and the contact number you would likethe password to be sent to.

Email Address for receipt of results

Mobile Number for password

If you are unable to email your application form, please post this to the below address:
Compliance TeamSynectics Solutions LtdPO Box 3700
Stoke-On-Trent
ST6 9ETIf you have opted to receive your results by email, you are confirming that you accept
responsibility for delivery of your personal data in this way. Please note, if this is a shared email
address, Synectics Solutions Ltd cannot accept any responsibility or liability for 3rd party
access and/or further dissemination of your personal data. Results will be password
protected and the password will be shared with your preferred contact number.
Section 3: DeclarationBy signing this document, you signify that you:Have read and completed all sections of this form accurately
Have enclosed a copy from list A
Have enclosed a copy from list B
Are the data subject whose name appears on this form

You are also consenting to the information you provide on this form being stored andprocessed for the purpose of fulfilling this request.

Signed:Date:
DDMMYYYY

Synectics Classification: Confidential (when completed)V.3.2