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Information Release Authorization

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________________________________________ _ The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of Adult Career and Continuing Education Services (ACCES-VR) VR-21 (3/15) Information Release Authorization Name: ________________________________________ ______________________________ Print full name The Office of Adult Career and Continuing Education Services (ACCES-VR) has my permission to Release or obtain Information from agencies [including the Client Assistance program (CAP)], individuals, or employers as are concerned with my vocational rehabilitation.

The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of Adult Career and Continuing Education Services (ACCES-VR) VR-21 (3/15)

  Information, Release, Authorization, Information release authorization

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