Release Of Information/proof Of Representation
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1RELEASE OF INFORMATION/PROOF OF REPRESENTATION
OFFICE OF ATTORNEY GENERAL
CRIME LABORATORY DIVISION
TOXICOLOGY SECTION
SFN53546 (12/2012)
To maintain confidentiality of our records, we ask that you provide this completed form prior to requesting any information from
our office. We suggest you keep a copy on hand for signature during your client's initial visit. No records will be released
without our receipt of this or an equivalent form.
Law Firm Completion
Firm Representing Client
Firm Contact Name
Telephone Number
Fax Number
Address
City
State
ZIP Code
Initial Court Appearance Date (If known)
Client Completion
Client Name (Please print and include middle initial)
Clients Driver's License Number
State
Date of Birth
Date of Offense
I, the above named client or legal representative, hereby acknowledge that the above firm is representing me and may have
access to any and all records concerning my case file(s).
Client or Legal Representative Name
Relationship to Client
Signature
Date
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