AUTHORITY FOR RELEASE OF INFORMATION

AUTHORITY FOR RELEASE OF INFORMATION

Background Check Authorization Form
I authorize the North Carolina Department of Public Safety through the State Bureau of Investigation, Special Operations Division, to perform a North Carolina name-based criminal history record information check in connection with my application for town employment with TOWN OF BURGAW pursuant to NC ORDINANCES - STATE ONLY.
Full Name*

First NameMiddle NameLast Name
Maiden Name
Social Security Number (Optional)
Date of Birth*

MonthDayYear
Date
Sex*
Race*
I understand that the North Carolina State Bureau of Investigation, Special Operations Division, and its officials and employees shall not be held legally accountable in any way for providing this information to the above named agency, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the agency cannot provide a hard copy of the results of this criminal history record check to me.

*Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exclusion of possible criminal history records.
Signature*

Clear
Date*

MonthDayYear
Date
This form must be maintained on file with the above named agency for one year. Do not mail this form or a copy of this form to the State Bureau of Investigation.
Should be Empty: