Authorization For Release Of Employment Records

410 WEST ARDEN AVENUE TEL (818) 265-1020

•

•

SUITE 203

•

GLENDALE, CA 91203

FAX (818) 265-1021 • WWW.AIWAZIAN.COM

AUTHORIZATION FOR RELEASE OF PERSONNEL FILE, PAY STUBS, AND TIME RECORDS _____________________________________________________

I, Robin Cabanyog, request that American Medical Systems send a copy of the following documents to The Aiwazian Law Firm, located at 410 West Arden Avenue, Suite 203, Glendale, California 91203: 1) My employee personnel file in its entirety; 2) My pay stubs, wage stubs, and time records in their entirety, 3) My business-related expense reimbursement records in their entirety; and 4) Any and all other records that relate to my compensation, time scheduled or worked, or other employee-related matters, including but not limited to “service call reports” and “indirect time reports.” _______________________ Print Name

________________________ Social Security Number

______________________ Signature

________________________

PRIVILEGED AND CONFIDENTIAL

Date