Authorization to Release Information
Authorize the release of your personal or account information to a designated third party.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your account #
*
Third Party's Full Name or Organization
*
First Name
Last Name
Third Party's Email Address
*
example@example.com
Third Party's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Specify the information you authorize to be released
*
Purpose of Information Release (optional)
Authorization Expiration Date (if applicable)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Authorizing Individual
*
Authorize and Submit
Authorize and Submit
Should be Empty: