Permission To Provide Information

 

To: __________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

 

RE: __________________________________________________________

______________________________________________________________

 

You are authorized to give WALL STREET BROKERS, Inc.,

any and all information and documentation requested at any time.

 

A copy or facsimile of this signed document is to be considered an original.

 

NAME (typed or printed):__________________________________________

Signature:______________________________________________________

NAME (typed or printed):__________________________________________

Signature:______________________________________________________

NAME (typed or printed):__________________________________________

Signature:______________________________________________________

cc: Wall Street Brokers, Inc.
9627 California Ave SW
Seattle WA 98136
Phone: 206.448.1160
Fax: 206.448.8476
e-mail: lorelei.stevens@gmail.com
URL: www.wallstreetbrokers.com
WSBI file #_____________