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Get Cgfns Authorization To Release Information

AUTHORIZATION I authorize CGFNS to release to the authorized agent indicated by me below any and all information about me and my application/order for services from CGFNS including and without limitation the status of my application/order the results of any credentials review examination or test and any other information in or relating to my file at CGFNS. I understand that all mail including certificates exam scores and reports will be sent to the authorized agent. Authorization to Release Information NOTICE By signing below you 1 allow CGFNS to disclose confidential personal private information about you and your file at CGFNS to the person designated below 2 give up the right to receive information from CGFNS directly and 3 release and indemnify CGFNS its members trustees officers and employees from any liability for losses damages or claims of any type arising out of actions taken by CGFNS in reliance upon this Authorization to Release Information hereafter known as Authorization. This Authorization will remain valid for two years from the date supplied by you on the Date line below or if no date is supplied from the date this Authorization is received by CGFNS. REVOCATION This Authorization can be revoked by submitting a new authorization dated and signed after the initial authorization* In addition you may revoke this Authorization in writing at any time which will be effective on or after the 30th day after CGFNS receives it by regular mail or courier at its headquarters office in Philadelphia Pennsylvania USA. 1 Your CGFNS ID number if known 2 Your birth date spell the month and enter numbers for the day and year Month Day Year 3 Your signature Date Do not print / Print your name 4 Your authorized agent please print Your contact s name The organization your contact is representing Day telephone Fax Evening telephone Email 3600 Market Street Suite 400 Philadelphia PA 19104-2651 USA 1 215 222 8454 www. This Authorization will remain valid for two years from the date supplied by you on the Date line below or if no date is supplied from the date this Authorization is received by CGFNS. REVOCATION This Authorization can be revoked by submitting a new authorization dated and signed after the initial authorization* In addition you may revoke this Authorization in writing at any time which will be effective on or after the 30th day after CGFNS receives it by regular mail or courier at its headquarters office in Philadelphia Pennsylvania USA.

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