AUTHORITY FOR RELEASE OF INFORMATION
To The Office of the Judicial Administrator:
I hereby authorize Brigid Beachler, on behalf of the Dean of the School of
Industrial and Labor Relations, to obtain all information regarding any disciplinary action
on record against me in the Office of the Judicial Administrator for my participation in
the ILR Credit Internship Program or the ILR Credit Internship Program.
I hereby request that the Office of the Judicial Administrator release my
disciplinary record to Brigid Beachler upon receipt of this release. This release is given
with the knowledge and understanding that the information obtained under it will be
used to certify the status of my disciplinary record to the appropriate requesting agency.
This release is valid until rescinded in writing by the requester. Should there be any
question as to the validity of this release, you may contact me as indicated below.
Signature:
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Full Name:
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Other Names Used:
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I. D. Number:
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School/Year:
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Date:
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Ithaca Address:
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Telephone:
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Permanent Address:
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Telephone:
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