RELEASE OF INFORMATION AUTHORIZATION
Completion of this form is requested by Pierce County, for the purpose of completing a background check, should you receive a conditional offer of employment. Personally identifiable information on this form will be used for no other purposes.
(For official use only, not to be released to unauthorized persons.)
As evidence of my desire to obtain employment with Pierce County, I hereby empower Pierce County to, while my application for employment is pending, obtain information and records pertaining to me including, but not limited to, the following:
I hereby authorize my social security number to be used in criminal record checks.
I hereby release any individual or institution, including its officers, employees or related personnel, both individually and collectively, from any and all liability damages of whatever kind, which may at any time result to me, because of compliance with this authorization and request to release information or any attempt to comply with it.
I understand that if an applicant provides false or misleading information on their application it may result in a refusal to hire or if already hired, discipline up to and including termination of employment. An applicant who does not want to submit to a background check may withdraw his or her application from consideration.
Full Name: _____________________ __________________ ____________________
Last Middle Name First
Address: ________________________________________________________________
Date of Birth __________________ Social Security Number: ____________________
Signature ________________________________________ Date _______________________