Authorization to Disclose Information. Buyer authorizes the Buyer’s lender(s), the parties’ real estate agent(s) and closing attorney: (1) to provide this Contract to any appraiser employed by Buyer or by Xxxxx’s lender(s); and (2) to release and disclose any buyer’s closing disclosure, settlement statement and/or disbursement summary, or any information therein, to the parties to this transaction, their real estate agent(s) and Xxxxx’s lender(s). Except as herein otherwise provided to the contrary, this agreement shall be binding upon and inure to the benefit of the undersigned parties hereto, their personal representatives, successors and assigns. Purchaser and Seller declare and expressly acknowledge that each has read and fully understands the terms set forth in this Contract. This offer remains binding and irrevocable through . If this offer is not accepted by the Seller by said date the xxxxxxx money deposit shall be returned and this agreement shall be null and void. The foregoing offer is ACCEPTED by the Seller on . PURCHASER: SELLER: _ . By: By: As its: Date: Date: By: By: Date: Date: BROKER: House Auction Company By: As its: / NC R.E. Lic # Date: By signing here, Xxxxxx acknowledges receipt of the xxxxxxx money as more particularly described herein. Purchaser’s Initials Seller’s Initials EXHIBIT “A” A certain lot or parcel of land situated in the Town of Spring Hope, Mannings Township, Xxxx County, State of North Carolina , more particularly described as follows: STREET ADDRESS: 000 X. Xxxxxx Xxxxxx, Xxxxxx Xxxx, XX 00000 . (LEGAL DESCRIPTION): That parcel bearing Parcel Identification Numbers 007616 located at 213 N. Walnut Street, in the Town of Spring Hope, NC and further described in Deed Book 2099, Page 340, Xxxx County Registry . PARID: 007616 PIN: 286018206376 Deed Ref: Book 2099, Page 340 . EXHIBIT “B”
Authorization to Disclose Information. Buyer authorizes the Buyer’s lender(s), the parties’ real estate agent(s) and closing attorney: (1) to provide this Contract to any appraiser employed by Buyer or by Xxxxx’s lender(s); and (2) to release and disclose any buyer’s closing disclosure, settlement statement and/or disbursement summary, or any information therein, to the parties to this transaction, their real estate agent(s) and Xxxxx’s lender(s).
Authorization to Disclose Information. To Primary Care Physician If you are an insurance client, you must fill out this form. If you do not want your records released to your Primary Care Physician, check the third option below, sign and print your name. I understand that my records are protected under the applicable state law governing health care information that relates to mental health services and under the federal regulations governing Confidentiality of Alcohol and Drug Abuse patient Records 42 CRF Part 2, and cannot be disclosed without my written consent unless otherwise provided for in state or federal regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. This release will automatically expire twelve months from the date signed. I, hereby authorize (Please Print Client’s Name) (Please Print Treating Counselor’s Name) Please check any that apply: To release any applicable information to my Primary Care Physician To release medication information only to my Primary Care Physician Not to release information to my Primary Care Physician (Client’s or Client’s Guardian Signature) (Date) (Please Print the above Name) (Date) Primary Care Physician: Name: Address: Phone:
Authorization to Disclose Information. Each of the undersigned individuals makes the following statement to FCM, in his or her own capacity: I/We hereby authorize FCM to disclose to the physician, clinic or storage facility named above the cryopreservation report(s), thawing instructions and results of my infectious disease testing and other medical information pertaining to the embryos. The purpose for these disclosures is to provide the Recipient with information it will need to store, thaw or otherwise handle the embryos.
Authorization to Disclose Information. You authorize us to disclose your name and address to third-parties involved with providing 911 dialing to you, including, without limitation, call routers, call centers and local emergency centers.
Authorization to Disclose Information. Seller authorizes: (1) any attorney presently or previously representing Seller to release and disclose any title insurance policy in such attorney's file to Buyer and both Xxxxx's and Seller's agents and attorneys; (2) the Property’s title insurer or its agent to release and disclose all materials in the Property's title insurer's (or title insurer's agent's) file to Buyer and both Buyer's and Seller's agents and attorneys and (3) the closing attorney to release and disclose any seller’s closing disclosure, settlement statement and/or disbursement summary, or any information therein, to the parties to this transaction, their real estate agent(s) and Xxxxx’s lender(s).
Authorization to Disclose Information. NINETEEN. The BORROWER authorizes the LENDER to disclose information related to the operation contained in this agreement to the extent such information is required of the LENDER by the funding sources for financial purposes. MISCELLANEOUS
Authorization to Disclose Information. Seller authorizes: (1) any attorney presently or previously representing Seller to release and disclose any title insurance policy in such attorney's file to Buyer and both Xxxxx's and Seller's agents and attorneys;
Authorization to Disclose Information. Except as otherwise set forth herein or allowed by law, I do not authorize the release of any information to others not acknowledged above. I wish to be a “no information” patient, and I realize that flowers, telephone calls and visitors will be refused on my behalf. (Patient’s Initials: )
Authorization to Disclose Information. Buyer authorizes the Buyer’s lender(s), the parties’ real estate agent(s) and closing attorney: (1) to provide this Contract to any appraiser employed by Buyer or by Xxxxx’s lender(s); and (2) to release and disclose any buyer’s closing disclosure, settlement statement and/or disbursement summary, or any information therein, to the parties to this transaction, their real estate agent(s) and Xxxxx’s lender(s). Except as herein otherwise provided to the contrary, this agreement shall be binding upon and inure to the benefit of the undersigned parties hereto, their personal representatives, successors and assigns. Purchaser and Seller declare and expressly acknowledge that each has read and fully understands the terms set forth in this Contract. This offer remains binding and irrevocable through . If this offer is not accepted by the Seller by said date the xxxxxxx money deposit shall be returned and this agreement shall be null and void. The foregoing offer is ACCEPTED by the Seller on . PURCHASER: SELLER: By: By: As its: Date: Date: By: By: Date: Date: BROKER: House Auction Company, Inc. By: As its: / NC R.E. Lic # Date: By signing here, Xxxxxx acknowledges receipt of the xxxxxxx money as more particularly described herein. EXHIBIT “A” A certain lot or parcel of land situated in the Township, County, North Carolina , more particularly described as follows: (LEGAL DESCRIPTION): Being all that property as described STREET ADDRESS: . PIN: Deed Reference: . Map Reference: . EXHIBIT “B”
