Free 50667.FH11 - Indiana

AUTHORIZATION TO RELEASE INFORMATION TO THE INDIANA BOARD OF ACCOUNTANCY
State Form 50667 (R / 4-07)

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INDIANA BOARD OF ACCOUNTANCY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3040 E-mail: [email protected]

I, ___________________________________________ having made application for licensing with the Indiana Board of Accountancy and desiring that they be informed of any personal records pertinent to my application, hereby authorize an investigation into all or any employment records, which may be of interest to them. This authorization includes, educational and employment records, whether privileged or not. This authorization to furnish information is executed in consideration of the Indiana Board of Accountancy giving my license application consideration and shall serve as a release of all liability to all parties furnishing such information to the Indiana Board of Accountancy and / or their authorized agents. A photocopy of this release shall be considered as effective and binding as the original copy.
Signature of applicant Date (month, day, year)

STATE OF COUNTY OF

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Subscribed and sworn to before me this ________ day of ____________________________________, 20________.

Signature of Notary

Printed Name of Notary

Date commission expires (month, day, year)

County of residence

NOTARY SEAL