Third-Party Information Release Authorisation

This form allows Meli to release information about you to a nominated third party. Only complete this section if you are authorising another person to act on your behalf or receive information about you, including private information.

Name(Required)

First Name Surname

Address(Required)

Street Address Address Line 2 City State Post Code Country

I hereby give permission for the people names in Schedule One (Authorised Persons) to(Required)

act as my representative / agent;

view and/or receive my personal information; or

both act as my representative / agent and to view and/or receive my personal information.

Schedule One - Authorised Person 1 (Required)

Full Name(Required)

First Name Surname

Company Name (if applicable)

Phone(Required)

Email(Required)

Schedule One - Authorised Person 2 (Optional)

Full Name(Required)

First Name Surname

Company Name (if applicable)

Phone(Required)

Email(Required)

Duration of Authority(Required)

One-time search to locate and release the requested information.

Valid until the following date

Ongoing until revoked

Please confirm valid until date(Required)

Note, if the person who received the services is under the age of eighteen, the authority automatically expires when that person turns eighteen and must be given again.

Signature(Required)

This field is hidden when viewing the form

Date(Required)