Authorization For Release Of Educational Information
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Authorization For Release Of Educational Information Form. This is a Kentucky form and can be use in Workers Comp.
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Tags: Authorization For Release Of Educational Information, Kentucky Workers Comp,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
7/02
Plaintiff(s)
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
Kentucky Labor Cabinet
:
Department of Workers’ Claims
:
Authorization for Release of Educational Information
Defendant(s)
:
......................................................
I, __________________________, having received a retraining incentive benefit award
and desiring to participate NEW YORK
THE PEOPLE OF THE STATE OFin retraining do hereby authorize any school, training facility, or
TO
person, institution, corporation or governmental agency to disclose or release any requested
educational information including grades, training progression, and class attendance and other
related educational matters to the Department of Workers Claims, Department of Vocational
GREETINGS:
Rehabilitation, self-insured employer, insurance carrier or Division of Workers Compensation
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable This authorization includes the examination and copyingCourt desired documents or
at the
Funds.
of any
located at
County of
in room records. , on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Signed at ______________________, Kentucky, this the ______________ day of
___________________________, 200____.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
_______________________________
Claimant’s Signature
, one of the Justices of the
day of
, 20
_______________________________
Social Security Number
(Attorney must sign above and type name below)
_______________________________________
Witness Signature
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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