CLARK COUNTY SUPERIOR COURT
CLARK COUNTY SUPERIOR COURT
GUARDIAN AD LITEM REGISTRY RELEASE
(To Be Enclosed With Your Application)
Date: / / LICENSE NUMBER
To: Washington State Bar Association
Washington State Medical Association
Washington State Nursing Commission
Washington Board of Psychology
Washington State Department of Licensing
Other:
I, , hereby authorize you, for the purpose of my application and/or work as Guardian ad Litem for the Clark County Superior Court, to release information to and discuss such information with:
Clark County Superior Court
PO Box 5000
Vancouver, WA 98666-5000
This RELEASE includes, but is not limited to, all records and information concerning any official disciplinary action or any pending active investigation you have with regard to me.
____________________________________
Signature
Printed Name
Street Address
City/State/Zip Code
Telephone No./Fax No.
________________________________________________________________________
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