Authorization For Release Of Information Form printable pdf download

AUTHORIZATION FOR RELEASE OF INFORMATION

I am an applicant for a position with the _______________ Department. The

department needs to thoroughly investigate my employment background and personal

history to evaluate my qualifications to hold the position for which I have applied. It

is in the public’s interest that all relevant information concerning my personal and

employment history be disclosed to the __________________ Department.

I hereby authorize any representative of the ___________ Department bearing this

release to obtain any information in your files pertaining to my employment records,

and I hereby direct you to release such information upon request of the bearer. I do

hereby authorize a review of and full disclosure of all records, or any part thereof,

concerning myself, by and to any duly authorized agent of the

____________________ Department, whether said records are of public, private or

confidential nature. The intent of this authorization is to give my consent for full and

complete disclosure.

I further consent to your release, including photocopies, of any and all public and

private information that you may have concerning me, my work record, my

background and reputation, my military service records, my educational records, my

financial status, my criminal history record, including any arrest records and any

information contained in investigatory files, efficiency ratings, complaints or

grievances filed against me. I further request release of attendance records, polygraph

examinations and any internal affairs investigations and discipline, including any files,

which are deemed to be confidential and/or sealed.

I understand my rights under Title 5 USC § 552a, the Privacy Act of 1974, with regard

to access and disclosure of records, along with 51 OS § 24A.8, with regard to Open

Records Act, and I waive those rights with the understanding that information

furnished will be used by the ______________________ Department in conjunction

with employment procedures.

I hereby authorize the National Personnel Records Center, St. Louis, Missouri, or

other custodian of my military record (if applicable) to release to the

________________________ Department information or photocopies from my

military personnel records. This could include photocopies of my DD214 Report of

Separation, etc.

A photocopy of this release form will be valid as an original thereof, although the said

photocopy does not contain an original writing of my signature. Should there be any

questions as to the validity of this release, you may contact me at the address or phone

number listed on this form.

Authorization For Release Of Information Form