TO WHOM IT MAY CONCERN: I am an applicant for a position with the City of Walhalla (COW). The department needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold this position for which I applied. It is in the public’s interest that all relevant information concerning my personal employment and credit history be disclosed to this agency.
I hereby authorize any representative of the COW bearing this release to obtain any information in your files pertaining to my employment records and I hereby direct you to release such information upon request to the bearer. I do hereby authorize a review of full disclosure of all records, or any part thereof, concerning myself, by and to any duly authorized agent of COW, whether said records are of public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure. I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life for the specific purpose of pursing a background investigation that may provide pertinent data for COW to consider in determining my suitability for employment in that department. It is my specific intent to provide access to personnel information, however personal or confidential it may appear to be.
I consent to your release of any and all public and private information that you may have concerning me, my work record, my background, and reputation, my military service records, my credit and financial records, my criminal history record including any arrest records, any information contained in investigatory files, efficiency ratings, complaints or grievances filed by or against me, the records or recollections of attorney’s at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which, I presently have or have had an interest, attendance records, polygraph examinations and any internal affairs investigations and discipline, including files which are deemed to be confidential and/or sealed.
I hereby release you, your organization and all others from liability or damages that may result from furnishing the information requested, including any liability or damage pursuant to any state or federal laws. I hereby release you as the custodian of such records of the organization, including its officers, employees or related personnel, both individually and collectively , from any and all liability for damages of whatever kid, which may at anytime 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. I direct you to release such information upon request of the duly accredited representative of the COW regardless of any agreement I may have previously made with you to the contrary.
For consideration of the COW acceptance and processing of my application for employment, I agree to hold your organization, its agents and employees harmless from any and all claims and liability associated with my application for employment or in any way connected with the decision whether or not to employee me with the COW. I understand that should information of a serious criminal nature surface as a result of this investigation, such information may be turned over to the proper authorities.
I understand my rights under Title 5, United States Code Section 552a the Privacy Act of 1974 with regard to access and disclosure of records and I waive those rights with the understanding that information furnished will be used by the COW in conjunction with employment procedures.
A photocopy or FAX copy of this release form will be as valid as an original thereof, even though the said photocopy or FAX copy does not contain an original writing of my signature.
This waiver is valid for a period of sixty (60) days from the date of my signature. Should there be any questions as to the validity of this release you may contact me at the address listed on this form. I agree to pay any and all charges or fees concerning this request and can be billed for such charges at the address listed on this form.
I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees from and against all claims, damages, losses and expenses, including reasonable attorney’s fees arising out of or by reason of complying with this request.
