Free Authorization and Release Form - Kentucky

Form 419B -WDKY

United States District Court
W ESTERN DISTRICT OF KENTUCKY

______________________________ RE: APPLICATION FOR ADMISSION - AUTHORIZATION AND RELEASE

I, _______________________________________________, whose Social Security Number is ______________________, having filed an application for admission to the Bar of this Court consent to have an investigation made as to my moral character, professional reputation and fitness for the practice of law and such information as may be received, reported to the admitting authority. I agree to give any further information which may be required in reference to my past record. I also authorize and request every person, firm, company, corporation, governmental agency, court, association, or institution having control of any documents, records, or other information pertaining to me, to furnish to the Clerk, United States District Court for the Western District of Kentucky any such information, including documents, records, bar association files regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, and to permit the said Clerk to inspect and make copies of such documents, records and other information. I hereby release and discharge, the state admission agency of the state(s) of my admission, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, and other information to or by the said Clerk. I have read the foregoing document and have furnished all information fully and frankly. The information is complete and true of my own knowledge.

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(Signature of Applicant)

Subscribed and sworn to before me this _____________ day of _______________, 2009.

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