Parkville Police Department 8880 Clark Avenue Parkville, Missouri 64152 (816) 741-4454
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I ________________________________________ do hereby authorize a review and full disclosure of all
records concerning myself to any duly authorized officer of the City of Parkville, Missouri, and it’s Police
Department, whether the said records are of a public, private, or confidential nature.
The intent of this authorization is to give my consent for full and complete disclosure of the records of
educational institutions; financial or credit institutions, including records of loans, the records of commercial
or retail credit agencies (including credit reports and/or ratings) and other financial statements and records
wherever filed’ medical and psychiatric treatment and/or consultation including hospitals, clinics, private
practitioners, and the U.S. Veteran’s Administration; employment and pre-employment records, including
background reports, efficiency ratings, complaints or grievances filled by or against me; records and
recollections of attorneys at law, or of other counsel, whether representing me or another person in any
case, either criminal or civil, in which I presently have or have had an interest; and records involving any
incident where I have been convicted of a crime.
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, may be considered in
determining my suitability for employment by the City of Parkville, Missouri. I understand that (1) the City
states that the use of such information will be in accordance with it’s employment policies and that such
information will not be used for any other purpose other than for consideration of the above as an employee
of the City, and (2) this background check is required because of the nature of the particular position that
I have made application in that it involves a sensitive position of person(s) who may furnish such information
concerning me shall not be held accountable for giving this information; and I do hereby release said
person(s) from any and all liability, which may be incurred as a result of furnishing such information.
A photocopy of this release form will be valid as an original thereof, even though the said photocopy does not
contain an original writing of my signature.
Print Name Notary Public
Maiden or other name by which you have been known Date