HomeMy WebLinkAboutWaiver and Authorization to Release Information 2020Pasco Police Department
215 W. Sylvester
Pasco, Washington 99301-5320
(509) 545-3421/ Fax (509)545-3423
WAIVER AND AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN:
In exchange for the consideration by the Pasco Police Department of my application for
employment, I authorize you to provide to the Pasco Police Department any and all information you might
have concerning me, my work record, my reputation, my military service record, and my financial status,
including any information that may be deemed confidential or privileged. This information is necessary for
the Department to determine my qualifications and fitness for the position which I am seeking with the
Pasco Police Department.
I understand my rights under Title 5, United States Code, Section 552(a), the "Privacy Act of
1974", and waive those rights with the understanding that information furnished will be used by the Pasco
Police Department in conjunction with the application and future employment with the Department.
I further release the provider of this information from any and all liability or damages which may
result from the furnishing of the information requested above.
I further authorize the release of any information received by the Department in the evaluation of
my application (including the release of all test results) for employment to another law enforcement
agency.
I further agree that a photocopy reproduction of this Waiver and Authorization to Release
Information shall for all intents and purposes be treated as an original. This Waiver and Authorization shall
be valid for a period of one hundred and eighty (180) days from the date written below.
I hereby waive my right, now and in the future, to examine, review, or otherwise discover the contents of
this investigation and all related documents thereto.
DATED this ____________ day of __________________________, 2______.
Applicant:
Type or Print Name Social Security Number
Signature
SUBSCRIBED AND SWORN TO before me this _________ day of______________, 2_____.
_________________________________________________
Notary Public in and for the State of Washington.
Residing in ________________________________________
My Commission Expires: __________________________