DOC request three complete - Cannabis Defense Coalition

. I, Offender Name
STATE OF WASHINGTON
DEPARTMENT OF CORRECTIONS
rllc'p C/r~Ur'Lto
release a copy of - . ..... -
..
-.' to:
NAME
REPRESENTING
MAILING ADDRESS
CITY, STATE, ZIP CODE
hereby authorize
AUTHORIZATION FOR RELEASE OF
CUSTODIAL iNFORMATION .'
Vi ;;'S-.J (, "1'1- (,,0 1 r
Releasing Authority Name.I)r-,O,r~aJ2J
Name {}Q...p ~ ci 0..H, /' -e c/,:ct'y)CJ
. Representing . ~ CZ--v( C'\....Q s(. -G~'·
Mailing.Address --= ' Sit S', D> A..Jot. 3+.
City, State ZipCode I. i / .. '\ .
. JlvC:-+- " (/....x.-r fI. OY\ f/v ~
!
. The information is released for the following reasons:
Enter Reasons
/0 'U~i~o- ~ ~ yr~ ~ f'o-L
THE FOLLOWING INFORMATION MAY BE RELEASED: .
D
D
D
D
Educational History
Random UfA Results
Progress in Treatment'
Presentence Report
D· Criminal History
D
Reports to Court I Board
D . Assessment or Reassessment of Risk Forms·
o LSI/RMIIOAP Interview Data
.0. ,. C~urt or Board Orders 4.,.~ fae~F,
~ Other (Specif~): f1U~3(:.· C~ an0'l-' I
., Itc-Pa- /..e.J tv f1{O-r ('/I o-e . tu~
. . . 9"-1'7' -O~ ()~/rr-/ CccJZlcJ-A ~ /J .
.' . f/'-esc-/'! Q{..roV\ (tY1.t1!-r,' rV~
NOTE: For release of medical: dental, and mental health information, use DOC 13-035, ALI
Health Information.
orization for Disclosure of
For release of drug and alcohol treatment information, use DOC 14-303, Chemical Dependency - Consent for the
Release of Confiden~iallnformatfon,
'if releasing to criminal justice agencies.
/
(CONSENT IS SUBJECT TO REVOCATION AT ANYTIME.)
.L{ --I" -0 t
DATE
WITNESS
PROHIBITION ON RED IS CLOSURE: THIS FORM HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALLY
IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED. ANY AUTHORIZATION SPECIFYING "ANY AND
ALL INFORMATION" SHALL NOT BE HONORED. . .
The contents of this document may be eligible for public disclosure. Social Security Numbers are considered confidential information and
will be redacted in the event of such a request. This form is governed by Executive Order 00.03, RCW 42.56, and RCW 40.14,
1
DOC 09-485 (Rev. 03/21/07)
PDU-6655-3 000232