ACCOUNT_FIRST_NAME ACCOUNT_LAST_NAME

ACCOUNT_ADDRESS_SINGLE_LINE

Tel: ACCOUNT_PHONE_NO  Email: ACCOUNT_EMAIL

To NAME

[Address]

19 November 2024

Subject: Third-Party Release Authorization

Dear Manager,

I hereby authorize the FULL_NAME to request and obtain my  documents from NAME. I authorize the release of the following information:

INFORMATION_DESCRIPTION

This authorization is valid from 19 November 2024 and will remain in effect until EXPIRY_DATE, unless otherwise revoked in writing. 

I declare that I have made this authorization voluntarily and the information on this form is true and correct. I understand that I may withdraw my consent at any time by giving notice in writing to the NAME. I further understand that this withdrawal of consent shall not be retroactive. 

By signing below, I acknowledge that I have read and understood the terms of this Third-Party Release Authorization and consent to the release of my information 

........................................