Tohono O'odham Nation, Executive Branch
HUMAN RESOURCES DEPARTMENT
P.O. Box 837; Sells, Arizona 85634 ~ Phone: (520) 383-6540 ~ Tucson (520) 295-2464
Fax: (520) 383-4676 ~ Website: www.tonation-nsn.gov
In consideration of my employment or being considered for employment, by the Tohono O’odham Nation, do
hereby give permission to release any information on the following to the
Human Resources Office.
Conviction of a felony
Misdemeanor or conviction
Conviction for DUI or other major traffic violations within the past three (3) years.
I also do hereby represent that I (have been) , (have not been) convicted of a felony or misdemeanor
involving moral turpitude, and authorize and consent to the disclosure by and to any law enforcement agency,
department or officer, to the Tohono O’odham Nation and the Bureau of Indian Affairs, or any of their Officers or
agents, any information that they may have or procure concerning my past record or character, hereby waiving any
protection I may have to the confidentiality thereof, and releasing them from any claim which may arise on account
thereof, or on account of the release or dissemination thereof.
PRINT FULL LEGAL NAME
SIGNATURE OF APPLICANT
Witness: Human Resources or Other: ____________________________________________
Date of birth: _____/_____/_____ Social Security Number: _____-___-_____
Driver’s License Number: ________________ Class: ________ Expires: _____/_____/_____
Address, City or village, state of residence for the past seven (7) years
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