Fillable NCCOB - Form MLA20 Authorization to Release Information

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NCCOB - Form MLA20 Authorization to Release Information

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The NCCOB - Form MLA20 Authorization to Release Information form is 2 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for North Carolina Office of the Commissioner of Banks

BROWSE NORTH CAROLINA OFFICE OF THE COMMISSIONER OF BANKS (NC) FORMS

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Location: 316 W. Edenton Street, Raleigh, NC 27603
Mailing Address: 4309 Mail Service Center, Raleigh, NC 27699-4309 (919) 733-3016 Fax (919) 733-6918 Internet: www.nccob.org
An Equal Opportunity / Affirmative Action Employer
MLA20
Rev. 03/29/2017
Office of the Commissioner of Banks
Roy Cooper
Governor
Ray Grace
Commissioner of Banks
AUTHORIZATION to RELEASE INFORMATION
I, _________________________, understand that pursuant to N.C.G.S. § 53C-2-7, certain records held
by the N.C. Office of the Commissioner of Banks (NCCOB) are confidential including complaints,
licensure applications, and related correspondence. I authorize the NCCOB to release confidential
information to the third parties listed below. I may also disclose any such information directly to a third
party without completing this authorization form. Please type or print the information requested
below.
NCCOB Records
Complaint No.: _____________________________
If applicable, please provide the following information:
Loan/Account No.: _______________________________________________
Company Name: _________________________________________________
Company License No./NMLS ID No., if known: ________________________
NMLS ID No.: _______________________
Your Information
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City/State/Zip: ________________________________________________________________________
Mailing address, if different from above: ___________________________________________________
_____________________________________________________________________________________
Telephone: _______________________________________
Email: __________________________________________
Signature: _______________________________________
Date of Authorization: _____________________________
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Location: 316 W. Edenton Street, Raleigh, NC 27603
Mailing Address: 4309 Mail Service Center, Raleigh, NC 27699-4309 (919) 733-3016 Fax (919) 733-6918 Internet: www.nccob.org
An Equal Opportunity / Affirmative Action Employer
MLA20
Rev. 03/29/2017
Authorized Third Party Information (Please Type or Print)
Name: _______________________________________________________________________
Company:_____________________________________________________________________
Title: ________________________________________________________________________
Telephone: ______________________________________
E-mail: _________________________________________
Name: _______________________________________________________________________
Company:_____________________________________________________________________
Title: ________________________________________________________________________
Telephone: ______________________________________
E-mail: _________________________________________
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NCCOB - Form MLA20 Authorization to Release Information

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Completed 23 May 2020

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