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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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