By Sending this order, I/we herewith authorize Kusar, Inc., and their representatives for the purpose of procuring/transferring all records in accordance with the directives contained
in this order form. The party ordering the records accepts responsibility for the cost of obtaining said records. In the event a third party is billed, the ordering firm is held responsible until
payment is received. The ordering party may be held liable for all costs associated with collections of this order.