Authorization to Release Information

Your First Name
Your First Name
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Your Last Name
Your Last Name
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Address:
Your Address
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City
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Zipcode
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Phone
Your Phone number
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To sign use your mouse or if on a mobile device sign with your finger.
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By signing this document you are authorizing the release of your information to Central Professional Services and it’s affiliates.

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Todays Date
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Signature authorized by customer
This is an attempt to collect a debt. Any information obtained will be used for that purpose. You are now communicating with a debt collector.