Financial Wellbeing – Referral Agency Authorisation

Referral Agency Name*
I authorise the following:*
- I hereby authorise you to divulge my contact details and other required personal data to any adviser/employee from the third party organisation named above in order to be able to make an effective referral.
- I authorise Bridge Community Project to share special category data (e.g. health, ethnic origin, criminal record) with the above third party organisation
- I authorise Bridge Community Project to keep a record of the referral made.
Client Reference Number*

This begins with BR and will be assigned by your adviser
Signature*
Name*
First Last
Date*
DD slash MM slash YYYY
Your data*
- Accept
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