Authority for Release of Information.pdf

FEDERAL BUREAU OF PRISONS

AUTHORITY FOR RELEASE OF INFORMATION

I hereby authorize any investigator or duly accredited representative bearing this release, or a copy thereof, within one year of its date, to obtain any information from schools, residential management agents, employers, criminal justice agencies, or individuals, relating to my activities. This information may include but is not limited to, academic, residential, achievement, performance, attendance personal history, disciplinary, arrest, and conviction records. I hereby direct you to release such information upon request of the bearer. I understand that the information released is for official use by the Federal

Bureau of Prisons and may be disclosed to such third parties as necessary in the fulfillment of official responsibilities.

I hereby release any individual, including regular custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with this authorization. Should there be any questions as to the validity of this release you may contact me as indicated below.

Signature (FULL NAME)______________________________________________________

Full Name (PRINT) ______________________________________________________

Other Names Used ______________________________________________________

Parent or Guardian ______________________________________________________

(If Required)

Date ______________________________________________________

Current Address ______________________________________________________

Telephone Number ______________________________________________________

PRIVACY ACT NOTICE

Authority for collecting information: E.O. 10450; USC 1303-1305; USC 2165 & 2455; 22 USC 2585 & 2519;

and 5 USC 3301.

Purposes and Uses: Information provided on this form will be furnished to individuals in order to obtain information regarding your activities in connection with an investigation to determine (1) fitness for federal employment, (2) clearances to perform volunteer or contract services for the federal government, (3) security clearances or access. The information obtained may be furnished to third parties as necessary in the fulfillment of official responsibilities.

Effects of non-disclosure: Furnishing the requested information is voluntary, but failure to provide all or part of the information may result in lack of further consideration for employment, clearance or access, or the termination of your employment.