Texas Department Of Public Safety Assumption Of Risks
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1THE STATE OF TEXAS:
Assumption of Risks, Covenant Not To Sue,
Authorization for Release of Personal
COUNTY OF _____________________:
Information, and Agreement of Assignment
KNOW ALL MEN BY THESE PRESENTS:
That I, the undersigned __________________________________________________________for and in consideration of being extended the
opportunity of undergoing physical agility testing and firearms qualification, when required, for the purpose of establishing my suitability for a
position with the Texas Department of Public Safety hereby do assume all risks of injury to my person arising out of or in any way incident to the
above-mentioned physical agility tests and firearms qualification; that each of the agility tests and firearms qualification have been described and
explained to me and I understand clearly what I will be called upon to do, and with this knowledge I assume whatever risk such test or tests may
entail to or accrue to my person; and that I, the undersigned, for the above-mentioned consideration have covenanted and hereby do covenant
never to sue or bring any legal or equitable action in any court whatsoever against the State of Texas or any officer or employee of the State of
Texas for any such injury.
Further, I, _______________________________do hereby authorize a review of and full disclosure of all records concerning myself to any duly
authorized agent of the Texas Department of Public Safety, including private vendors contracted by the Department for the purpose of conducting
a background investigation to determine hiring eligibility; whether the said records are of a public, private, or confidential nature.
The intent of this authorization is to give my consent for full and complete disclosure of the records of educational institutions; financial or credit
institutions, including records of loans; employment and pre-employment records, including background reports and polygraph examination (s),
efficiency ratings, complaints or grievances filed by or against me; and the records and recollections of attorneys at law, or other counsel, whether
representing me or another person in any case, either criminal or civil, in which I presently have, or have had an interest.
I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in
part, upon this release authorization will be considered in determining my suitability for employment by the Texas Department of Public Safety. I
also certify that any person(s) who may furnish such information concerning me shall not be held legally accountable for giving this information in
any way; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information.
I further agree that I may be assigned to any duty assignment upon initial employment or reinstatement or may be transferred as the needs of the
Department may require while employed with the Texas Department of Public Safety.
A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my
signature.
________________________________________
_______________________________________
Signature (include maiden name)
Date of Birth
________________________________________
_______________________________________
Address
Last Four SSN
________________________________________
_______________________________________
City, State, Zip
Phone#
________________________________________
_______________________________________
Witness
Witness Signature
RC-99 (Rev 04/15)
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