Authority To Release Information - New York State Department Of Financial Services printable pdf download

AUTHORITY TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

I hereby authorize any duly authorized representative of The New York State Department of Financial Services

(NYSDFS) bearing this release, or copy thereof, within one year of its date, to obtain any information in your files

pertaining to any professional license awarded to me (including any grievance records), Employment, military,

educational records (including, but not limited to, academic, achievement, attendance, athletic, personal history, and

disciplinary records), credit records, and law enforcement records (including, but not limited to any record of charge,

prosecution or conviction for criminal or civil offenses). I hereby direct you to release such information upon request

to the bearer. This release is executed with full knowledge and understanding that the information is for the official

use of the NYSDFS. Consent is granted for the NYSDFS to furnish such information, as is described above, to third

parties in the course of fulfilling its official responsibilities. I hereby release you, as the custodian of such records,

your employers, officers, employees, and related personnel, both individually and collectively, from any and all liability

for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of

compliance with this authorization and request to release information, or any attempt to comply with it. I am furnishing

my Social Security Account Number on a voluntary basis with the understanding such is not required by statute or

regulation. I understand that the NYSDFS will use this number only to assist the superintendent in making a

determination as to whether I meet the standards set forth in the banking law for receiving the charter, license or

registration for which I am applying. Should there be any question as to the validity of this release, you may contact

me as indicated below.

I have read the above release and agree to the terms and conditions therein.

Social Security Account Number:____________________________________________

Date of Birth:____________________________________________________________

Parent or Guardian:_______________________________________________________

(if required)

Date:__________________________________________________________________

Current Address:_________________________________________________________

_________________________________________________________

Telephone Number:______________________________________________________

CPA/ Bar Membership(s)

State______________________________________

Registration Number__________________________

Full Name ______________________________________________________________

(Signature)

Full Name ______________________________________________________________

(Typed or Printed)

(Include maiden and any other previously-used name)

STATE OF ____________________:

SS:

______________________ COUNTY:

Before me, a Notary Public in and for said County and State, personally appeared the above-named

____________________________________ who acknowledged that ____________________ did sign the foregoing

instrument and that the same is _____________________ free and voluntary act and deed.

IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal at _____________________,

______________________, this ____________ day of _____________, 20 ____________

______________________________________

Notary Public

Authority To Release Information - New York State Department Of Financial Services

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