Form Qr 500.261 Customer Authorization Of Disclosure Of Financial Records - California Department Of Corporations

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STATE OF CALIFORNIA
DEPARTMENT OF CORPORATIONS
CUSTOMER AUTHORIZATION OF DISCLOSURE
OF FINANCIAL RECORDS
Pursuant to Corporations Code Section 25241 and Government Code Sections 7470 and 7473, any
financial institution, wherever situated, possessing financial records of
Name of (check appropriate designation(s) below)
Broker-Dealer
Investment Adviser
is hereby authorized to disclose to the California Department of Corporations records of the above-
named broker-dealer or investment adviser business 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 above-named broker-dealer or investment adviser license,
including renewals of such license.
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 licensee has duly caused this authorization to be signed on its behalf by the
undersigned, thereunto duly authorized.
Executed on _______________________, 20______ at _______________________________________
_______________________________________
_____________________________
Name of Licensee
Licensee’s Department of
Corporations File Number
By ______________________________________
______________________________________
(Title)
QR 500.261 (1/00)

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