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NAME:______________________________________ ______ _______________________________________________________
First Name Middle Initial Last Name
PREVIOUS NAME OR ALIAS (Include Maiden name): _____________________________________________________________
RESIDENTI
AL ADDRESS: ___________ ________________________________________________________________________
(Not a Post Office Box) Number
Street
__________________________________________ _____________________________________________ _________________
City/Town
State Zip Code
MAILING ADDRESS (If different)_______________________________________________________________________________
SOCIAL SECURITY NO.: DRIVERS LICENSE NUMBER:___________________________
DATE OF BIRTH
:
PLACE OF BIRTH:_______________________________________________________
I, , do hereby authorize a review of and a full disclosure of all records, or any part thereof, concerning myself,
by and to ANY duly authorized agent of the Department of State Police, whether the said records are public, private or confidential in nature.
The intent of this authorization is to give my consent for a full and complete disclosure of the records of educational institutions; financial or credit
institutions, including records of deposits, withdrawals and balances of checking and saving accounts, and loans, and also the records of commercial or retail
credit agencies (including credit reports and/or ratings); public utility companies; employers including but not limited to employment and pre-employment
records, background reports, efficiency ratings, complaints and/or grievances filed by me or against me, and salary records; real and personal property tax
statements and records, and other financial statements and records wherever filed; records of complaint, arrest, trial, and/or convictions for alleged or actual
violations of the law, including criminal, civil and/or traffic records; records of complaint of a civil/probate nature made by or against me, wheresoever
located, and to include the records and recollections of attorneys at law, or of other counsel, whether representing me or another person in any case in which I
presently have an interest.
I reiterate, and emphasize that the intent of this authorization is to provide full and free access to the background and history of my personal life, for the
specific purpose of pursuing a background investigation which may provide pertinent data for the Department of State Police to consider in determining my
suitability for employment by the Department of State Police. It is my specific intent to provide access to personal information, however personal or
confidential it may be, and the sources of information specifically identified herein.
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 in determining my suitability for employment by the Department of State Police. I understand that all materials
pertaining to this background investigation become the property of the Department of State Police and will not be returned or provided to me.
I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees, from and against all claims, damages,
losses and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request. I further understand that in the event my
application is disapproved, the sources of confidential information cannot and will not be revealed to me.
I understand a photocopy of this release form will be valid as an original hereof, even though said photocopy does not contain an original writing of my
signature.
MUST BE SIGNED IN THE PRESENCE OF A NOTARY
On this, the ________ day of _____________________, 20___, before me, the Signature:
undersigned Notary Public, personally appeared __________________________,
proved to me through satisfactory evidence of identification, which was/were Street Address
________________________________ to be the person whose name is signed
on this document and who swore or affirmed to me that the contents of the City:
document are truthful and accurate to the best of his/her knowledge and belief.
State:
Notary Public Zip Code:
The Commonwealth of
Massachusetts
Department of State
Police
Human Resources Section
470 Worcester Road, Framingham, MA 01702
(508) 820-
2292