AUTHORIZATION FOR RELEASE OF INFORMATION
Applicant


Address

Birth date
Sex
Social Security
Have you lived in any other state(s) besides Oklahoma in the past three (3) years?
Yes
No
If yes, please list

This authorization is in compliance with the Privacy Act of 1974 (Public Law 93-579). The information you authorize released will be used to verify data provided on your employment application or upon hiring and is necessary for employment in a specific position. If any information you have provided is determined to be false after the hiring process is complete, you will be terminated immediately. Information determined to be false prior to hiring will result in your not being hired.

The information obtained as a result of your signature on this authorization will be furnished to designated officers and employees of Canadian County to verify information necessary to process your employment/volunteer work with the Canadian County Children’s Justice Center.

This authorization for release of information constitutes your consent for CCCJC to examine and/or obtain copies and abstracts of records and to receive statements and information regarding your background. By signing this form you authorize the release of data, records and information to Canadian County as designated below. Education, criminal and employment verification will be obtained on every person hired. Other information will be verified as legally required for a specific position.

Employment
Education
Criminal
Other (please specify)
Signature of Applicant
Date