Date ____________________________
 
 
 
 

TO WHOM IT MAY CONCERN:
 

1, the undersigned hereby authorize any doctor, hospital, ambulance owner or nurse who is now, or has been attending me to give the ___________________________________any information concerning any injuries, medical history and/or physical condition.

I hereby authorize________________________________ and any firm or employer by whom I am or by whom I have been employed to give the _________________________all information and evidence in their possession regarding wages, hours, time lost from work and nature of my employment.

(Badge or Time Clock Number _____________________________________)
 
 
 
 
 
 

THIS IS NOTA RELEASE OF CLAIMS FOR DAMAGE

                                                                                         X ------------------------------------------------------------
                                                                                                                                Signature
 
 

Amuit Coeptis Form 490D