waiver form

City of East Ridge Department of Public Safety Police Services 4214 Ringgold Road East Ridge, Tennessee 37412 423/867-3718 423/867-9418 (FAX) AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION AND CRIMINAL/DRIVING HISTORY RECORD INFORMATION _________________________________________________________________________________________________________ I, __________________________________________________, do hereby authorize the review and full disclosure of all records concerning myself to any duly authorized agents of the City of East Ridge, 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 records of educational institutions, financial or credit institutions, including records of commercial or retail credit agencies (including credit reports/ratings; and of financial statements wherever filed; medical and psychiatric treatment or consultation, including hospitals, clinics, private practitioners, and the United States Veterans Administration; employment and pre-employment records, including internal investigations, reports, background reports, polygraph exam results, efficiency or fit-for-duty reports, complaints, or grievances filed by or against me; and the records, recollections of attorney at law, or other counsel, whether representing me or another person in a case, either criminal or civil, in which I presently have or have had an interest; and any other document or article of information obtained by a personal history background investigation, which is developed directly or indirectly in whole or in part, upon release authorization will be considered in determining by suitability as a candidate for employment by the City of East Ridge. I also certify that any person(s) who may furnish such information concerning me shell not be held accountable for giving this; and hereby release them from any liability which may be incurred as a result of furnishing such information. I hereby authorize that City of East Ridge to receive any criminal history information and driver’s history information pertaining to me which may be in the files of any criminal justice agency. A photocopy of this release form will be as valid as an original thereof. ____________________________________________________________________________________ APPLICANT’S SIGNATURE: ____________________________________________________________ CURRENT ADDRESS: ________________________________________________________________ STATE: _______ ZIP CODE: _______ HOME PHONE #: __________ CELL PHONE: ___________ RACE: __________ SEX: __________ DOB: __________ SSN: _______________________ DRIVER’S LICENSE #: __________________________________________ STATE: ____________