HRA Felonious Assault Waiver Form

Felonious Assault Waiver
HRA Membership Number:
Member First Name
Member Last Name
# Email
example@example.com
Member ID, if applicable.
Store Number
Address of Business:
Street Address Line
City
State
Zip Code
I acknowledge that I have been given the option to participate in the Felonious Assault Program. I confirm that the selection made below reflects my decision to accept or decline.

AcceptDecline.
If Completed by a 3rd party on your Behalf

The attached document in absentia hereby authorizes HRA to complete my expressed wishes. This authorization in the attached form will remain in effect until I modify or cancel it in writing.
File Upload

Cancelof
Member Signature

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Date

MonthDayYear
Should be Empty: