Form A
CONSENT TO DISCLOSURE OF PERSONAL INFORMATION
(Please Print Legibly) Social Security Number _____________________ Date Received ______________
Last Name (Provide previous name(s) if applicable)
First & Middle Name
Maiden Name or Other Last Names Used (if applicable)
Place of Birth
Date of Birth (MM-DD-YY)
Telephone
( )
Sex
M / F
Race
B / W / H / O
Drivers License Number
Address (Street Name & Number) Apt/Unit
City State/Country Postal/Zip Code
Provide Previous addresses if you did not reside at the above address for more than five years
Address (Street Name & Number) Apt/Unit
City State/Country Postal/Zip Code
Address (Street Name & Number) Apt/Unit
City State/Country Postal/Zip Code
Reason for Request (Screening for Employment)
Search Authorization:
I HEREBY CONSENT TO THE SEARCH OF:
A. Criminal Record (Adult)
B. Criminal Record (Youth)
C. Records of Not Guilty by Reason of
Mental Competence
D. Charges Pending or Outstanding Under
Federal Statutes
E. Pending Charges Under the Child and
Family Services Act
F. Records of Convictions for Offenses Under
the Child and Family Services Act
G. Highway Traffic Act
H. Liquor Control Act
I. Other Police Service Information
Note: The presence of information does not necessarily mean the applicant will be disqualified from the position by the organization.
Form A
Release Authorization and Waiver
Authorization to Release Clearance Report or Any Police Information
Signed this ___________________ day of __________________________ 20_______
I certify that the information set out by me in this application is correct to the best of my ability. I hereby
release and forever discharge all members and employees of the processing Police Service from any and
all actions, claims and demands for charges, loss or injury howsoever- which may hereafter be sustained
by me as a result of the disclosure of information by the processing Police Service to the organization
listed herein.
_________________________________________________________________
Signature of Applicant
STAMP OF ORGANIZATION WITH RETURN ADDRESS:
__________________________________________________________________
Organizations Representative (Please Print)
___________________________________________________________________
Signature of Organizations Representative
