[Code of Federal Regulations]
[Title 32, Volume 1]
[Revised as of January 1, 2008]
From the U.S. Government Printing Office via GPO Access
[CITE: 32CFR14 App A]

[Page 51]

                       TITLE 32--NATIONAL DEFENSE

              CHAPTER I--OFFICE OF THE SECRETARY OF DEFENSE

PART 14_QUALIFICATION OF CIVILIAN DEFENSE COUNSEL--Table of Contents

 Sec. Appendix A to Part 14--United States of America Authorization for
                         Release of Information

                        United States of America

                Authorization for Release of Information

(Carefully read this authorization to release information about you,
then sign and date it in ink.)

    I authorize the Chief Defense Counsel, Office of Military
Commissions, Department of Defense, his designee or other duly
authorized representative of the Department of Defense who may be
charged with assessing or determining my qualification for membership in
the pool of Civilian Defense Counsel available to represent Accused
before military commissions, to obtain any information from any court,
the bar of any State, locality, district, territory or possession of the
United States, or from any other governmental authority.
    This information may include, but is not limited to, information
relating to: Any application for a security clearance; my admission or
application for admission to practice law in any jurisdiction, including
action by the jurisdiction upon such application, together with my
current status with regard to the practice of law in such jurisdiction;
any sanction or disciplinary action to which I have been subject for
misconduct of any kind; and any formal challenge to my fitness to
practice law, regardless of the outcome of subsequent proceedings.
    I authorize custodians of such records or information and other
sources of information pertaining to me to release such at the request
of the officials named above, regardless of any previous agreement to
the contrary.
    I understand that for certain custodians or sources of information a
separate specific release may be required and that I may be contacted
for the purposes of executing such at a later date.
    I understand that the records or information released by custodians
and other sources of information are for official use by the Department
of Defense, only for the purposes provided herein, and that they may be
redisclosed by the Department of Defense only as authorized by law.
    Copies of this authorization that show my signature are as valid as
the original signed by me. This authorization is valid for five (5)
years from the date signed or upon termination of my affiliation with
the Department of Defense, whichever is later.

________________________________________________________________________
Signature (sign in ink) SSN

________________________________________________________________________
Date