Attachment 2 - Authorization for Release of Information.docx
DOCX document 17 KB Posted
- Attached to
- Statewide General Office Moving Services
- Solicitation number
- 300000263953931
- Issued by
- Missouri
About this file
This is an Authorization for Release of Information form for the State of Missouri and designated state agencies for use upon contract award. The form is not intended for inclusion with bid submissions and serves as part of the background investigation process for contractor eligibility. The authorization permits the State of Missouri and the relevant state agency to obtain and review all records and information related to the applicant, including documents, reports, and criminal history records, to determine the applicant's suitability to perform services for the state agency.
The applicant voluntarily authorizes the release of information and agrees to cooperate fully with any background investigation conducted by the state agency. By signing the form, the applicant releases from all liability the State of Missouri, the designated state agency, and any other persons, firms, corporations, or institutions providing the requested information. The form requires the applicant to provide their printed name, signature, date, birth date, and Social Security number.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| STATE 0000000521SL SW General Office Moving Services RFP.docx | DOCX document | |
| Attachment 1 - Region and County Map.pdf | ||
| Attachment 3 - Missouri Statewide Quarterly Admin Fee Report.xlsx | XLSX spreadsheet | |
| Attachment 4 - Missouri Statewide Contract Quarterly Admin Fee Usage Report.xlsx | XLSX spreadsheet | |
| Attachment 5 - Business Associate Provisions.docx | DOCX document | |
| Attachment 6 - Federal Fund Requirement Language.docx | DOCX document |
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Text version
Attachment 2 – Authorization for Release of Information
(DO NOT INCLUDE WITH BID SUBMISSION – FOR USE UPON CONTRACT AWARD ONLY)
STATE AGENCY NAME
AUTHORIZATION FOR RELEASE OF INFORMATION
TO WHOM IT MAY CONCERN:
I hereby authorize and request release to the State of Missouri, __________________ (INSERT STATE AGENCY NAME), any and all records and information, including, but not limited to, originals or copies of any records, documents, reports, and criminal history record.
I understand that the _________________(INSERT STATE AGENCY NAME) may conduct and/or review a background investigation before rendering a decision regarding my eligibility to perform services for the __________________(INSERT STATE AGENCY NAME), and that this authorization is a part of that investigation.
I voluntarily agree to cooperate in such investigation, and release from all liability or responsibility the State of Missouri, _________________ (INSERT STATE AGENCY NAME), and all other persons, firms, corporations, and institutions supplying the above requested information.
Applicant’s Name (Please Print)
Date
Applicant’s Signature
Birth Date
Applicant’s Social Security Number
File details come from the government source that posted it. Updated .