Fillable CAS 16 REQUEST FOR SCHOOL RECORDS Character Assessment (City of New York)

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CAS 16 REQUEST FOR SCHOOL RECORDS Character Assessment (City of New York)

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REQUEST FOR SCHOOL RECORDS
PD 407-169 (Rev. 08-19)
CAS – 16
List # ________________ Exam # _______________
Date: _________________
Character Assessment Section
235 E. 20th St.
New York, N.Y. 10003
_________________________
_________________________
_________________________
To Whom It May Concern:
Pursuant to the written communication below, it is requested that the New York City Police Department be furnished
information contained in the school records of the student named below who is a candidate for appointment to this
Department.
Specifically, it is requested that the information requested on the reverse side of this letter, including any pertinent
comments from former teachers or other school personnel, be furnished as it appears on your records.
Your prompt attention to this matter will be appreciated.
Sincerely,
__________________________________
Investigator, Squad #
AUTHORIZATION
I hereby authorize the release of any and all information contained in my school records or known to school personnel
and that such information and/or records be disclosed, furnished to, and/or examined by the New York City Police
Department for the purpose of determining my eligibility for appointment to the New York City Police Department. This
Authorization shall remain in effect until canceled by me in writing.
I acknowledge by this authorization that I release you from any obligation or liability in the disclosure of the contents of such
files and the professional observations or opinions contained therein.
_________________________________________ _____________________________________________
Full Name – Printed Candidate’s Signature
Date Of Birth: ______________________________
Attended School From: ______________________
To: ______________________
Social Security Number: _____________ – _________ – ______________
Attention: School Records
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Candidate Name: ____________________________________Social Security Number: ___________________________
Dates Of Attendance: __________________________ to __________________________________ Day / Evening
Degree, Diploma, Or Certifi cate Received: _______________________________________________________________
Previous School: ___________________________________________________________________________________
School Transferred To, If Any: _________________________________________________________________________
Truant, Lateness, Disciplinary Record: _________________________________________________________________
Home Address: ____________________________________________________________________________________
Date Of Birth: ________________________________ Place Of Birth: ________________________________________
PERSONALITY RATINGS – CHARACTER TRAITS
Please check applicable box for overall rating in each category.
POOR FAIR GOOD EXCELLENT
Dependability 
Cooperation 
Courtesy 
Appearance 
EXPLANATION OF TERMS
DEPENDABILITY: Student has a sense of duty, tries harder by himself, meets obligations promptly, and is trustworthy.
COOPERATION: Student serves the school, teachers, fellow students, and works together with others to improve
the group.
COURTESY: Student has good manners, is considerate in dealing with others, and is obliging and disciplined.
APPEARANCE: Student has good posture, neat habits about person, property, and work, and is neat in dress.
Is there any disciplinary record or other confidential information on file? Yes or No ___________________. If there is,
please elaborate below or if you would prefer to have the investigator contact you personally, please indicate below.
School Representative Title Telephone Number Date
___________________________________________________________________________________________________
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CAS 16 REQUEST FOR SCHOOL RECORDS Character Assessment (City of New York)

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Completed 31 December 2021

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