10 NOTARIZED ORIGINALS OF THE WITHIN DOCUMENT MUST
BE FILED WITH THE PETITION & REINSTATEMENT QUESTIONNAIRE
AUTHORIZATION AND RELEASE
I, __________________________, born at _________________________________________,
(Name)
(City)
(State)
on _____________________, having filed a petition for reinstatement to the Bar of the Supreme
(Date)
Court of Pennsylvania, consent to have an investigation made as to my moral character,
professional reputation and fitness for the practice of law and to have such information as may be
received reported to the Office of Disciplinary Counsel of The Disciplinary Board of the
Supreme Court of Pennsylvania, its agents, employees and representatives (hereinafter
collectively known as “Disciplinary Counsel”). I agree to give any further information which
may be required in reference to my past record.
I authorize and request every person, firm, company, corporation, governmental agency,
court, association or institution having control of any documents, records or other information
pertaining to me, to furnish to Disciplinary Counsel any such information, including documents,
records, bar association files regarding charges or complaints filed against me, formal or
informal, pending or closed, or any other pertinent data, and to permit Disciplinary Counsel to
inspect and make copies of such documents, records, and other information.
I specifically authorize Disciplinary Counsel to obtain the following:
a.
Any information from my official record on file with local Board No.
__________ of the Selective Service System, located in the City of _______________,
State of _____________; and hereby consent to and authorize the release of such
information by the Selective Service System.
b.
I hereby request and authorize the Department of ___________ (Army,
Navy, Air Force) to furnish to Disciplinary Counsel the record of each period of my
service in the ___________ (Army, Navy, Air Force) and to furnish the character of
service rendered for each period. My serial number was ______________________.
c.
I hereby request and authorize the Federal Bureau of Investigation to
release and furnish to Disciplinary Counsel any investigative records pertaining to me
and further consent to having agents and/or employees of said Bureau discuss said file
with Disciplinary Counsel.