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180

Appendix - Form 180-1 Notification of Request for Information

Procedures

Notification of Request for Information

 

To: _______________________________________________________________

 

This is to advise that _________________________________________________

 

Has requested information in regards to the following items:

 

__________________________________________________________________

 

__________________________________________________________________

 

__________________________________________________________________

 

__________________________________________________________________

 

Before this information is to be released, you must supply the Division with the                                                                                                     authorization to do so. In the consent form below, please signify if any specific                                                                                                       information is not to be released.

 

_____________________________________ ___________________________

Officer of the Division                                              Date

 

 

Authorization for Release of Information

 

I, ___________________________ , hereby authorize the above-noted officer of                                                                                                     the Division to release information in regards to the items stated above except                                                                                                     for (if any).

 

__________________________________________________________________

 

__________________________________________________________________

 

 

_____________________________________ ___________________________

Signature                                                                    Date

 

Validity of this authorization expires after 90 days from this date.

References:

Revised January 2014