Release Of Information

RELEASE OF INFORMATION TO: Washington State Bar Association Washington State Medical Association Washington State Nursing Commission Washington State Board of Psychology Washington State Department of Licensing I, ___________________________________________ (Professional License No.__________________) herby authorize you, for the purpose of my application and/or work as a Kitsap County Guardian ad Litem, to release information to and discuss such information with: Frank A. Maiocco, Jr. Court Administrator Kitsap County Superior Court 614 Division Street, MS-24 Port Orchard, WA 98366 (360) 337-7140 This RELEASE OF INFORMATION includes, but is not limited to, all records and information concerning any official disciplinary action or a pending active investigation you have with regard to me. ______________________________ ____________________ Signature Date _______________________________ Printed Name _______________________________ Street Address _______________________________ City/State/Zip