W.K.U. POLICE
DEPARMENT PERSONAL INQUIRY
WAIVER AUTHORITY FOR
RELEASE OF INFORMATION I authorize a review of and full disclosure of all
records concerning myself to any duly authorized agent of Western Kentucky
University Police Department, whether the records are of a public, private,
or confidential nature. I authorize
copies of these records to be given to The intent of this authorization is to give my Consent
for full and complete disclosure of the records of: educational institutions,
financial or credit institutions, including records of loans, records
of commercial or retail credit agencies, including credit reports and
ratings, and other financial statements and records where filed, medical
and psychiatric treatment or consultation, including hospitals, clinics,
private practitioners, and the U.S. Veteran’s Administration, and employment
and pre-employment records, including background reports, performance
evaluations, complaints or grievances filed by or against me and the
records and recollections of Attorney’s at Law, or other counsel, whether
representing me or another person in any case, either criminal or civil,
in which I presently have an interest. I understand that any information obtained by a personal
history background investigation, which is developed directly or indirectly,
in whole or in part, upon this release authorization, will be considered
only in determining my suitability for employment by A photocopy of this release form will be valid as an
original even though the photocopy does not contain an original writing
of my signature. Please Print: Applicant’s
Name:_______________________________________________________________________________ Address:
______________________________________________________________________________________ City:_______________________________________________________State:
_________ Zip:_______________ Date
of Birth _____________________________________Social Security Number________________________ Applicant’s
Signature: __________________________________________________ Date: __________________
Witness
Name (Print): __________________________________________________________________________
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