Page 1 of 2 KPD-230 Rev 09/00
Authorization for Release of Personal Information To
Law Enforcement Agencies for
Certification / Employment Purposes
RE: ___________________________________
(Name of Applicant)
To Whom It May Concern:
I am an applicant for a position with the Kannapolis Police Department. In order to determine
my suitability for employment, I understand that the Kannapolis Police Department, City of
Kannapolis, North Carolina must make a thorough investigation of my personal records and
personal background. It is in the public’s interest that all relevant information concerning my
personal and employment history be disclosed to the above agency.
Therefore, I, _______________________________________, Date of Birth:_______________,
Social Security No. ______________________, do hereby request and authorize any bank, credit
union, lending or financial institution, credit bureau, consumer report agency, retail business
establishment, former and present employer, educational institution, doctor or other health care
professional including mental health, alcohol treatment center, hospital or other repository of
medical records, insurance company, governmental agency, criminal and civil courts,
certification/licensing commission, military organization, and any other individual agency to
produce and provide copies of any and all information to the authorized agent of the Kannapolis
Police Department, Kannapolis, North Carolina regarding me whether of a privileged or
confidential nature.
Moreover, I hereby release the Kannapolis Police Department, City of Kannapolis, North
Carolina, from any civil or criminal liability whatsoever for seeking such requested information
and for evaluating such information as it relates to my employment with the City of Kannapolis.
And, I hereby release the issuing agency and its agents and employees, both individually and
collectively, from any and all liability for damages of whatever kind, which may at any time
result because of compliance with this authorization and request.
I further waive all right to inspect or review any information compiled in reference to my
application for employment as allowed by law. I do further authorize the Kannapolis Police
Department, its agents and employees, to release copies of any and all information to any agency
or entity regulating the certification, authority or conduct of law enforcement officers or
employees. This is to include, but not limited to: North Carolina Criminal Justice Education &
Training Standards Commission, North Carolina Sheriff’s Education & Training Standards
Commission, North Carolina Attorney General’s Office, agencies of other states and the federal
government, and the applicant/officer’s employing agency.
Page 2 of 2 KPD-230 Rev 09/00
I hereby acknowledge that this authorization is valid for a one (1) year or until the employment
application or investigative process has been completed, whichever is later.
A copy of this document is considered valid, just as the original.
I have read and fully understand the above statements.
______________________________________
Applicant / Officer Signature
_______________________________________
Printed Name
_______________________________________
Street Address
_______________________________________
City, State, ZIP
_______________________________________
Phone Number
STATE OF NORTH CAROLINA
COUNTY OF: ________________________________
Subscribed and sworn to before me,
this the _____ day of _____________________, 20____.
_____________________________________________
Notary Public Signature & Seal
My Commission Expires: ________________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome