Authorization_to_Release_Information_Form(2).pdf

US Army Corps of Engineers – Vicksburg District – Security and Law Enforcement Office Fax: 601.631.7918

CEMVK FL 620 Proponent: CEMVK-PM Apr 09

DEPARTMENT OF THE ARMY

VICKSBURG DISTRICT, CORPS OF ENGINEERS

4155 CLAY STREET

VICKSBURG, MISSISSIPPI 39183-3435

Authorization to Release Information

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, retail business establishments, or other sources of information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, 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 other 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 for the purposes stated above and may be redisclosed by the Government 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.

NAME (PRINT): _____________________________________________________________________________

ALIASES: __________________________________________________________________________________

PRESENT STREET ADDRESS:_________________________________________________________________

COUNTY:________________CITY:___________________________STATE: ______ ZIP:_________________

PREVIOUS ADDRESS: _______________________________________________________________________ (If moved in past 2 years)

COUNTY:________________CITY:___________________________STATE: ______ ZIP:_________________

SOCIAL SECURITY NUMBER: ________________________________________________________________

DATE OF BIRTH:____________________PLACE OF BIRTH:________________________________________

DRIVER’S LICENSE NUMBER:_________________________________________STATE:________________

HOME PHONE:_____________________________OTHER PHONE:___________________________________

DATE OF HIRE:_________________POSITION/JOB TITLE:_________________________________________

COMPANY:_________________________________________________________________________________

SUPERVISOR:___________________________SUPERVISOR’S PHONE:______________________________

Signature Date

Signature of Witness Date