Fill and Sign the Release Form Paper

Consent and Release Form for Fingerprinting and for Criminal Record Review I, ________________ (Name of Applicant) , understand that as an applicant for _____________________ (Name of Job) with ____________________ (Name of Employer) , I am required to be fingerprinted and to undergo a criminal record review. I do hereby consent to be fingerprinted and to said criminal record review; and I further agree to the following conditions and terms: 1. The fingerprints will be used to check the criminal history records of the Federal Bureau of Investigation (FBI), and (list any other agencies) _________________________________ ___________________________________________________________________________ . 2. I hereby authorize the FBI, and (list any other agencies) _______________________ _____________________________________________________ to release criminal history information history to __________________ (Name of Employer) . 3. I understand that all information provided to _____________________ (Name of Employer) , will be held in a confidential manner by ______________________ (Name of Employer) . 4. I hereby authorize the FBI, (list any other agencies) ___________________________ ____________________________________________________________________________ , and _________________________ (Name of Employer) , to retain a fingerprint card or related fingerprint information. 5. I understand and agree that I may be suspended, terminated, or disqualified from employment based on the findings of the criminal record review consistent with applicable laws and regulations of the State of ________________________ (Name of State) and ______________________ (Name of Employer) . 6. This waiver and its authority is valid as to until such time as the Applicant is no longer employed by _________________________ (Name of Employer) . Regarding the FBI and (list any other agencies) __________________________________________________________ _________________, this waiver and its authority is valid indefinitely. Witness my signature this the ________________ (date) . __________________________________ (Printed Name of Applicant) __________________________________ (Signature of Applicant) (Acknowledgment form may vary by state) STATE OF ______________ COUNTY OF _______________ Personally appeared before me, the undersigned authority in and for the said county and state, on this _____ day of _____________, 20_____, within my jurisdiction, the within named, ____________________________ (Name of Applicant) , who acknowledged that he executed the above and fore going instrument. _____________________ NOTARY PUBLIC My Commission expires: ______________________