Attachment_6_-_Authorization_for_Release_of_Information.pdf

Attachment 6

United States of America Authorization for Release of Information

Carefully read this authorization to release information about you, then sign and date it in ink.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation, to obtain any information relating to my activities from schools, residential management agents, employers, criminal justice agencies, retain business establishments, or other sources of information. This information may include, but is not limited to, my academic, residential, achievement, performance, employment history, and criminal history record information.

I Understand that, for some sources of information, a separate specific release will be needed and I may be contacted for such a release at a later date.

I Authorize custodians of records and sources of information pertaining to me to release such information, upon request of the investigator, special agent, or duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by the Federal Government only, to determine my suitability to work as a contract employee, and may be re-disclosed by the Government only as authorized by law.

Copies of this authorization that show my signature are valid as the original release signed by

me. This authorization is valid for two (2) years from the date signed or for the duration of my contract employment as an observer supporting the Observer

Program

Signature (Sign in Ink): Date Signed:

Full Name:

Other Names Used: Social Sec. Number:

Current Address (Street, City, State, Zip Code):

Home Telephone Number (include area code):