(Richland Police Department)

 

 

AUTHORITY TO RELEASE INFORMATION

 

TO WHOM IT MAY CONCERN:

 

I hereby authorize the Richland Police Department  and its authorized representatives bearing this release, or a copy thereof, within one year of its date, to obtain any information in your files pertaining to my employment, military, credit, education or medical records, including not limited to academic, achievement, attendance, athletic, personal history, and disciplinary records, medical records, and credit records.

 

I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for official use. Consent is granted to all parties to furnish such information, as described above, to third parties in the course of fulfilling its official responsibilities. I hereby release you, as custodian of such records, and any school, college, university, or other educations institution, hospital, or other repository of medical records, credit bureau, lending institution, consumer reporting agency, or retail business establishment including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or attempt to comply with it.

 

I am furnishing my Social Security Account Number on a voluntary basis with the understanding such is not required by any law or regulation.  I have been advised that all parties will utilize this number only to facilitate the location of employment, military, credit, and educational records concerning me in connection with this application. Should there be any question as to the validity of this release, you may contact me as indicated below:

 

Applicant’s Printed Full Name: ______________________________________

Address: _______________________________________________________     

   _______________________________________________________

Telephone Number: _____    _______________________

Applicant’s Notarized Signature: _____________________________________

 

 

Sworn to and signed before me, on this the _______ day of __________, ___________,

in and for ________________________ County, in the State of Texas.

Signature of Notary Public: _________________________________________

NOTARY SEAL

Printed Name of Notary Public:  ____________________________

My Commission Expires:  _________________________________