Third-Party Information Release Consent Form

Third-Party Information Release Consent Form
Complete this form to authorize a named third party to receive specific information as outlined below.
Your Full Name
First NameLast Name
Your Email Address
example@example.com
Name of Third Party to Receive Information
First NameLast Name
Third Party's Email Address
example@example.com
Please specify the information you authorize to be released
Purpose of Information Release
Third-Party Information Release Consent Form
By signing below, you authorize the named third party to receive the information specified above. You confirm that you understand the scope of this release and grant permission for the disclosure of this information for the purpose stated. This authorization is voluntary and may be revoked by you in writing at any time, except to the extent that action has already been taken in reliance on it.
Signature
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Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: