Personal Information Release Form

Personal Information Release Form

Personal Information
Applicant Name:
Date of Filing:
Social Security #:
ID Number:
Driver’s License:
Purpose for Release:
Type of Information to Release
	Social Security Information
	Medical Records
	Insurance Information
	Driving Records
	Other:

Authorized Personnel/Companies to Receive Aforementioned Information
Name #1:
Address #1:
Phone #1:		Email Address: #1:
Name #2:
Address #2:
Phone #2:		Email Address: #2:

I, the undersigned, do hereby swear that the aforementioned information is true and factual to the best of my knowledge. I authorize {Company/Contacts} to release the checked information to the aforementioned personnel.

Applicant Signature		Date Signed

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