RELEASE/ACQUISITION OF INFORMATION	Date
The individual identified is a prospective or current employee and is authorizing the release and/or acquisition of specific information.
Release/Acquisition of Information

The individual identified is a prospective or current employee of Life's New Beginnings, Inc., and is authorizing the release and/or acquisition of the specified information.
Individual (print)

Information is (check one)
TO BE RELEASED
TO BE ACQUIRED
Name of Service Provider or Authorized Representative Releasing Information

Name of Service Provider or Authorized Representative Acquiring Information

Specific information to be released/acquired (describe)

Form in which the information is to be released/acquired (check one)
Written
Verbal
Video
Audio
Other (specify)
Purpose of the information to be released/acquired (describe)

The release/acquisition of information request is authorized for thirty (30) days from the date of signature.

Individual	Signature	Date
Individual
Life's New Beginnings Owner