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Get Release Of Information - PERSI - Idaho - Persi Idaho

Lete the form in blue or black ink. Send form to PERSI. Note: The authorization that you provide on this form is valid until you notify PERSI in writing to revoke it. Member Information Name First, Middle, Last Social Security Number Street or P.O. Box Mailing Address City State Daytime Phone Number (include area code) Zip Code Email Address Individuals to Whom Information May be Released Name First, Middle, Last Street or P.O. Box Mailing Address City State State Zip Cod.

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