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Release Authorization JR

This document is an authorization for the release of personal information to the United States Department of State and the Office of Personnel Management. It allows designated agents to obtain various records related to the individual's academic, residential, employment, and legal history. The individual also releases any liability for damages resulting from the compliance with this authorization.

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6 views1 page

Release Authorization JR

This document is an authorization for the release of personal information to the United States Department of State and the Office of Personnel Management. It allows designated agents to obtain various records related to the individual's academic, residential, employment, and legal history. The individual also releases any liability for damages resulting from the compliance with this authorization.

Uploaded by

rutdiantitan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DEPARTMENT OF STATE

Washington, D. C. 20520

AUTHORITY FOR RELEASE OF INFORMATION


TO WHOM IT MAY CONCERN:

I hereby authorize any Special Agent or Investigator of the United States Department of
State, or any Investigator or duly accredited representative of the United States Office of
Personnel Management bearing this release, or a copy thereof, within one year of its date,
to obtain any information from schools, residential management agents, employers,
criminal justice agencies, credit agencies or individuals, relating to my activities. This
information may include, but is not limited to, academic, residential, achievement,
performance, attendance, personal history, disciplinary, arrest and conviction records,
and credit information. I hereby direct you to release such information upon request of
the bearer.

I hereby release any individual, including record custodians, from any and all liability for
damages of whatever kind or nature which may at any time result to me on account of
compliance, or any attempts to comply, with this authorization. Should there be any
question as to the validity of this release, you may contact me as indicated below.

Full Name: __________________________________________

Other Names used: __________________________________________

Current Address: __________________________________________

__________________________________________

Telephone: __________________________________________

Signature: __________________________________________

Date: __________________________________________

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