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Customer Authorization Of Disclosure Of Financial Records QR 500.259 - California

Customer Authorization Of Disclosure Of Financial Records Form. This is a California form and can be used in Securities Regulation Division Blue Sky Secretary Of State .
 Fillable pdf Last Modified 12/9/2013
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STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT DBO-QR 500.259 (Rev. 8/13) CUSTOMER AUTHORIZATION OF DISCLOSURE OF FINANCIAL RECORDS Pursuant to Corporations Code Section 25134 and Government Code Sections 7470 and 7473, any financial institution, wherever situated, possessing financial records of the sale of ___________________________________________________________, securities qualified for sale Name or Title of Securities under the Corporate Securities Law, by __________________________________________________________________________________ Name of Applicant seeking qualification of securities under the Corporate Securities Law is hereby authorized to disclose to the California Department of Business Oversight records of the sale of the above-named qualified securities whether such records relate to accounts which have been closed, accounts which are currently maintained, or accounts which are hereafter established. This authorization is effective as of the date of execution and shall remain effective until five years after the expiration or revocation of the qualification of the above-named securities, including renewals of such qualification. This authorization may not be revoked. The terms used in this authorization shall have the definitions contained in the California Right to Financial Privacy Act (Government Code Section 7460 et seq.) and the Corporate Securities Law (Corporations Code Section 25000 et seq.). The above-named applicant has duly caused this authorization to be signed on its behalf by the undersigned, thereunto duly authorized. Executed on__________________________, 20 ____, at ____________________________________ ____________________________________ Department of Business Oversight File Number ___________________________________ Name of Applicant By _______________________________ _______________________________ (Title) American LegalNet, Inc. www.FormsWorkFlow.com DBO-QR 500.259 (Rev. 8/13) Page 2 of 2 STATE OF CALIFORNIA ­ DEPARTMENT OF BUSINESS OVERSIGHT CUSTOMER AUTHORIZATION OF DISCLOSURE OF FINANCIAL RECORDS INSTRUCTIONS FOR CUSTOMER AUTHORIZATION OF DISCLOSURE OF FINANCIAL RECORDS FORM On the reverse is a Customer Authorization of Disclosure of Financial Records form. The Commissioner of Business Oversight is authorized to require such authorization from certain licensees and other persons pursuant to the authority cited in the first paragraph of the form. The form must be properly executed and submitted with the attached application for license, qualification, registration or other authority. All information required on the form, except the signature of the person executing the form, is to be typewritten. If the form requests a Department of Business Oversight file number, the applicant need only provide such number if it is known to the applicant and is the type of file number appropriate for the license, qualification, registration or other authority applied for in the attached application. If additional authorization forms are needed, they may be obtained from any office of the Department of Business Oversight, or accurate copies of the form may be utilized by applicants. American LegalNet, Inc. www.FormsWorkFlow.com
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