worker-comp-law_W3_A3

Release of Information and Authorization

I, _______________________________ hereby consent to the release of:

(student inserts relevant language here)

to: Law Offices, 123 Main St., Anytown, IL 11001

For the purpose of: (student inserts relevant language here).

I understand that this release of information can be revoked by me at any time in writing. This release of information is valid for one year from the date of execution.

Signed:___________________________

Date:____________________________