Central Registry Information Release Authorization Form
Please complete this form to authorize the release of central registry information. All fields are required for processing your authorization request.
Full Name of Requestor
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Agency Name (if applicable)
Name of Recipient (Person or Organization to Receive Information)
*
Recipient's Email Address
example@example.com
Reason for Release of Information
*
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Authorization
Submit Authorization
Should be Empty: