Release of Information Form

DAWSON COMMUNITY COLLEGE
AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize my employer, through their agent, Verified Credentials, to obtain information related to past employment, employers, school activities, verification of education, criminal justice agencies, motor vehicle/registration departments, credit checks, professional licensing registries, or other relevant sources of information.

This Information may include, but is not limited to, information about my academic achievement, performance, attendance, disciplinary, employment history, criminal history record information, credit screening, and driving and motor vehicle record.

I authorize Verified Credentials to disclose the record of my background investigation to my employer or prospective employer.

I authorize custodians of records and other sources of information pertaining to me to release such information to Verified Credentials regardless of any previous agreement to the contrary. I release my employer Services, its officers, employees, and agents, from any liabilities resulting from release of such information

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for one (1) year from the date signed or upon my termination of employment with the employer, whichever is sooner.

__________________________________                         ____________________________

Signature                                                                                                  Date

Full Name (Print Legibly):_______________________________________________________________

Other Names Used:___________________________________________________________________

Current Address: _____________________________________________________________________

Other State(s)/Cities of Residency last 10 years:  ________________________________________________

Home Phone: _______________________________Work/Cell Phone: ____________________________
Date of Birth:________________________________________________________________________
Place of Birth: _______________________________________________________________________
Social Security Number: ____________________     Drivers License Number & State: ___________________

 

 

Authorization for Release w/credit

 

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