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2. I also understand and acknowledge that I have read this <br />Authorization to Release and Disclose Information and Documents (hereinafter <br />"Authorization"), that I understand all of the provisions of this Authorization, <br />and that I am signing this Authorization as my free and voluntary act. <br />3. I also understand and acknowledge that I have the right to revoke this <br />Authorization at any time by providing a written notice of revocation to BCRC <br />at the address listed above. Any such revocation shall not be effective until <br />BCRC receives such written revocation and any such revocation shall not be <br />effective as to any action taken by BCRC with respect to this Authorization <br />prior to BCRC's receipt of such written revocation. <br />4. I also understand and acknowledge that BCRC has no obligations <br />to exercise any control over the use by the Receiving Parties, including further <br />disclosure by the Receiving Parties, of any information and/or documents <br />that BCRC releases and/or discloses to the Receiving Parties pursuant to this <br />Authorization. I hereby release and waive any claims that I may have against <br />BCRC relating to the use by the Receiving Parties, including further disclosure <br />by the Receiving Parties, of any information and/or documents that BCRC <br />releases and/or discloses to the Receiving Parties pursuant to this Authorization. <br />5. I agree to defend, indemnify and hold harmless BCRC from any and <br />all claims and liabilities relating and/or arising from BCRC's compliance with <br />this Authorization. <br />Signature: <br />Name (Printed): <br />Address of Signer: <br />Date Signed: <br />BCRC ID No.: <br />Soc. Sec. No. <br />Date of Birth: <br />Driver's License No: <br />57 <br />