Model Template Agency Release Of Information Form - Manegait Page 2

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I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any
time either orally or in writing.
Date:______________
Signed:________________________
Time:______________
Witness:______________________
Reaffirmation and Extension
(if additional time is necessary to meet the purpose of this release)
I confirm that this release is still valid, and I would like to extend the release until ___________
___________
New Date
New Time
Signed:__________________________
Date:______________
Witness:_________________________

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