WAIVER AND AUTHORIZATION TO RELEASE INFORMATION
To Whom it May Concern:
I am an applicant for a police officer position with the Everett Police Department. I do hereby authorize you to
release to the Everett Police Department any and all records and/or information which you may have concerning me,
including, but not limited to, information/records related to my reputation, employment and attendance records,
school transcripts, military service records and financial status. Information of a confidential or privileged nature may
be included. Your rep
ly will be used to assist the Everett Police Department in determining my qualifications and
fitness for the position I am seeking with the Department.
I understand my rights under Title 5, United States Code, Section 552a, the Privacy Act of 1974 and waive those rights
with the understanding that information furnished will be used by the Everett Police Department in conjunction with
I understand that any information obtained by the Everett Police Department for its personal history background
investigation that is developed directly or indirectly, in whole or in part, upon this release authorization becomes the
property of the Everett Police Department and I will not have access to any of the background investigation. I further
understand and acknowledge that the Everett Police Department may provide certain types of information that is
obtained in the course of its ba
ckground investigation to my current employer, such as information about criminal
activity or serious policy violations. initials
I hereby waive and release you, your organization, employees, and agents from any and all claims, liability, personal
injuries, damages or losses, of any nature, which may result from furnishing the requested information.
I hereby waive, release and hold harmless the City of Everett, its officers, employees, agents, and any current or
former employers, any schools or educational and technical institutions and their employees or agents, and the
employment references specifically named from any and all claims, lawsuits, personal/bodily injuries, damages or
losses, of any nature, resulting from the release of any information requested by the City of Everett in connection
with my application for emplo
yment by the City. My authorization and release from liability are voluntary acts and
shall be effective only for employment investigations by the City of Everett.
Print Applicant Name Signature of Applicant
Subscribed and sworn to before me on the day of , 20 .
Notary Public for State of WA
Note: A photocopy reproduction of this request form shall be, for all intent and purposes, as valid as the original. You
may retain this form in your files.