California State University Bakersfield Community Page

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Public Safety
Application For Release Of Information
Date of Application: Receipt Number:
Type of Report: Traffic Collision Crime Other Incident
L ocation of Occurrence:

Name of Driver or Property Owner:
Name of Applicant/Agent:
Date of Occurrence: Report Number:

 

PARTY OF INTEREST
(please check one)


Person Involved Authorized Individual Property Owner (Signed Authorization Required) Parent/Guardian of Juvenile Party Representative of Insurance Company or Adjusting Agency Attorney (or agent for Attorney)
Other Party of Interest: (Please Specify)

CERTIFICATION
I declare under the penalty of perjury that:
I am,
I represent,
an attorney representing the party reported hereon.


____________________________
Signature

____________________________
Date

 

 


Last modified on: Sat., Sep. 02, 2006 - 03:49:47 PM
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