I hereby authorize Roger Williams University School of Law, its Minority Business Law Collaborative(“MBLC”) and their respective directors, officers, employees and agents, to verify, disclose, disseminate and copy any and all information provided in this Application for Legal Services in the course of determining eligibility for legal services and/or during the course of legal representation, if the MBLC agrees to provide legal services to me and/or the above-referenced business. The MBLC will determine which applicants will receive legal services based upon several factors, including the need of the applicant, program requirements/restrictions and the capacity of the MBLC.

In consideration for the MBLC’s review of eligibility for legal services and/or its provision of legal services, as applicable, I, on behalf of myself and/or the above-referenced business, hereby forever release the School of Law, the MBLC, and their respective directors, officers, employees and agents from any and all claims resulting
from or relating to the disclosure, at any time, of any information and documents provided in this Application for Legal Services.

I further understood and agree that the MBLC may release information about me and/or the above-referenced business to third parties, including the Rhode Island Department of Commerce and the Rhode Island Pandemic Recovery Office. Accordingly, I, on behalf of myself and the business, hereby authorize the MBLC to
disclose certain information as may be required by the MBLC’s funders and others, including, but not limited to, my name and the name of the business, that I and/or the business is/are a client of the MBLC, and the general nature of legal services performed by the MBLC, as applicable.

I agree to promptly notify the MBLC in the event that any information provided herein has changed, and I understand and agree that the MBLC has the right to reject any applicant, or withdraw from representing a client, who submits an Application for Legal Services containing inaccurate information.

I hereby certify that all of the information in this Application for Legal Services is true, correct, accurate and complete, and I represent and warrant that I am authorized to submit this Application for Legal Services and sign the Authorization to Release Information on behalf of the above-referenced business.

A copy of this Application for Legal Services and Authorization to Release Information shall be
deemed as valid as the original.