Georgia > Statewide > Insurance And Safety Fire Commissioner
Authority For Release Of Information GID-53 - Georgia
| Authority For Release Of Information Form. This is a Georgia form and can be used in Insurance And Safety Fire Commissioner Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
OFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONER COMMISSIONER OF INSURANCE ·INDUSTRIAL LOAN COMMISSIONER·SAFETY FIRE COMMISSIONER·COMPTROLLER GENERAL Ralph T. Hudgens, Commissioner 2 Martin Luther King Jr., Dr., Suite 604, West Tower, Atlanta, GA 30334 Phone: 404-656-7556 Fax: 770-344-5798 E-mail: TBrewster@oci.ga.gov www.oci.ga.gov Authority For Release Of Information NON-TRADITIONAL ENTITIES GID-053-NT FEB11 (same as GID-053-EN) I, , presently reside at and am affiliated with, or proposed to be affiliated with, which as applies for licensure or a permit to organize by the Office of Commissioner of Insurance. I understand that the Office of Insurance will conduct an investigation of my background. hereby waive any right of confidentiality as it reasonably relates to this inquiry. In that regard, I I hereby give my permission and waive any provisions of law that forbids any court, policy agency, employer, firm, or person, disclosing any knowledge or information they have concerning me which is requested by the Office of Commissioner of Insurance. I further consent and request that the supervisor of the Non-Traditional Section in the Enforcement Division or his/her representative be provided with the performance of their investigation. I recognize the right of the Office of Commissioner of Insurance to treat, at its discretion, certain sources as confidential, and right to withhold from my agent or me the names of such confidential sources, and information obtained therefrom. Applicant's Signature Date This document was executed and signed in the presence of the following witnesses: Witness-1 Signature Witness-2 Signature County of Date Date State of Sworn to and Subscribed before Me this day of My Commission Expires , NOTARY ( Seal ) Signature This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs services. Disabled persons needing this r document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056. o Page 1 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
