Authorization_for_Release_of_Information_(scanned).pdf

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

I Authorize any investigator, special agent, or other duly accredited representative of the National

Gallery of Art conducting my background investigation to obtain any information relating to my activities from employers and criminal justice agencies. This information may include, but is not limited to, my achievement, performance, attendance and disciplinary employment history, and my 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 other duly accredited representative of the National Gallery of Art 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 National Gallery of Art only for the purposes provided herein and may be redisclosed by the National Gallery of Art only as authorized by law.

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

This authorization is valid for two (2) years from the date signed.

Full Name (Type or Print Legibly) Signature (Print COMPLETE MIDDLE NAME below) (Sign in ink) Last First Middle

Other Names Used Date of Birth Social Security (mm/dd/yyyy) Number

Current Address (Street, City) State ZIP Code

Driver’s License Number State License Telephone Number Date Signed Issued By (Include Area Code)

COMPLETE THIS FORM AND SUBMIT TO THE NATIONAL GALLERY OF ART’s COTR.

National Gallery of Art Washington, DC

AUTHORIZATION for

RELEASE of INFORMATION (per Specifications Section 01 3553)