I, [full name] born on [date:] in [City/County, State/Province, Country:] hereby:

(A)	authorize the Hawaii Board of Bar Examiners and the National Conference of Bar Examiners to furnish and provide to each other and the Supreme Court of Hawaii all documents, records or other information pertaining to me that may relate to my eligibility to engage in the practice of law.

(B)	agree that all information provided by my application for admission to the bar of the State of Hawaii and all other information received by the Hawaii Board of Bar Examiners may be released and shared with, by, and between the Hawaii Board of Bar Examiners, the National Conference of Bar Examiners, and the Supreme Court of Hawaii at any time and without liability to the Hawaii Board of Bar Examiners, the National Conference of Bar Examiners, or the Supreme Court of Hawaii.

Signature (Sign in black ink)

State of	)

) ss.

County of	)

On this day of , , personally appeared before me, executed the foregoing document, and acknowledged that executed the instrument as free act and deed.

Subscribed and sworn to or affirmed before me this day of , .

Signature of Notary (Sign in black ink)

My commission expires: