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Form 08-1468c - Authorization For Release Of Records - Alaska Division Of Occupational Licensing

Authorization for Release of Records

To Whom It May Concern:

residing at

authorize the Alaska Division of Occupational Licensing and its investigators to examine my medical, dental,

employment, and educational records, and records pertaining to litigation, suits, judgments and/or settlements, and

any law enforcement records pertaining to me and discuss them with persons having possession of them. I also

expressly permit and authorize the release of any and all such records pertaining to me to the Alaska Division of

Occupational Licensing and its investigators.

I authorize the Division to discuss my records with persons or organizations which are considered appropriate by the

Division in connection with an official investigations, and to provide copies of my records to those persons or

organizations deemed appropriate by the Division.

This release also applies to any documents or records which contain information pertaining to psychiatric, drug or

alcohol evaluation, diagnosis or treatment received by me and which were prepared or made in conjunction with, or

under the authority or guidance of any local, state, or federal law which relates to psychiatric, drug or alcohol

evaluation, diagnosis, or treatment.

I request that upon presentation of this release, or a Certified True Copy, that you provide copies of the records to the

Division and/or its investigators, and/or representatives of the Office of the Attorney General of the State of Alaska.

This authorization is given expressly in connection with my application for licensure as a pharmacy intern.

Social Security Number:

Date of Birth:

Home Telephone:

Work Telephone:

Signature:

Date:

08-1468c (Rev. 7/00)

Form 08-1468c - Authorization For Release Of Records - Alaska Division Of Occupational Licensing