AUTHORIZATION
TO RELEASE INFORMATION
TO
WHOM IT MAY CONCERN:
Having made application for employment with the
Nevada Department of Corrections and desiring it to be informed as to my
previous record and character, I hereby authorize any peace officer or other
authorized representative of the Nevada Department of Corrections bearing this
release or a copy of it, within one year of its date, to obtain information in
your files pertaining to my employment, pre-employment, military, arrest,
conviction, driving, credit or educational records, including but not limited
to, academic, achievement, attendance, athletic, personal history, performance
report, background investigations, polygraph examination results, any and all
internal affairs investigations and disciplinary records, and credit records.
I also hereby authorize any peace officer or other
authorized representative of the State of Nevada Department of Corrections
bearing this release or a copy of it, within one year of its date, to obtain
any medical records or medical information in the files of my current or former
employer(s) or any current or former physician(s), or both, which pertain to my
employment.
I hereby direct you to release this information up
request of the bearer. This release is
executed with full knowledge and understanding that the information is for the
official use of the Nevada Department of Corrections.
Consent is granted for the Nevada Department of
Corrections to furnish the information described above to third parties in the
course of fulfilling its official responsibilities.
I hereby release you, as the custodian of such
records, and any law enforcement or criminal justice agency, school, college,
university, or other educational 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
damage 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 any attempt to comply with it. Should there be any questions as to the
validity of this release, you may contact me as indicated below.
A photocopy of this release will be valid as an
original thereof, even though the said photocopy does not contain an original
writing of my signature.
I understand that I have the right to receive a copy
of this authorization and acknowledge that I have received a copy of it.
_________________________________________________ ________________________
Signature Date
_________________________________________________ ________________________
(In
accordance with the Federal Privacy
Address:
_________________________________________________________ Act of 1974, disclosure of the
S.S.N. is
voluntary. The S.S.N. will be used only for
identification purposes to
ญญญญญ_________________________________________________________ that proper
records are obtained.)