Consent to Disclose Personal Information

By signing this form, you authorize the release of the following personal information by the school listed below to
its designated third-party, Synergy, for the purpose of verifying your eligibility for an elective

Name Name First Last
Email
Alternative Email
Campus
Date of Birth Date of Birth / MM / DD YYYY
School Applying To
Intake
University Student Number

Use your student number used in the AFMC portal.
MINC Number
Specialty/Subspecialty
International Student

International Student Yes No
Terms of Agreement

Terms of Agreement I have completed all fields I understand the purpose for disclosing this personal information to the third-party, Synergy. I understand that I can refuse to sign this consent form.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.