04/07
Office of Social Equity ▪ 1871Old Main Drive, Room 200 ▪ Shippensburg, PA 17257 ▪ www.ship.edu ▪
(717) 477-1161
InformationReleaseAuthorization
I, ____________________________, hereby authorize any educational institution, any past or present employer
(including any branch of the armed services), any local, state, or federal government agency (including any law
enforcement or security agencies) to release to Shippensburg University through its authorized representative(s)
bearing this authorization, all information concerning me.
I voluntarily agree to this investigation of my background with the knowledge and understanding that whatever
information is obtained is for the official use of Shippensburg University and will not be released to any other
parties.
I further understand any information obtained during such investigation may only be used to determine my
fitness, competence, and ability for the purpose of employment with Shippensburg University.
I release Shippensburg University from any liability which may result from making this investigation.
Furthermore, I hereby forever release anyone who has knowledge or information concerning my employment
history and criminal history from any claims or demands from liability or damages for disclosure of true and
accurate information provided by this investigation. This authorization shall supersede and counter name any
prior request or authorizations to the contrary.
I further authorize the use of photocopies of this authorization.
Signature: ____________________________ Date: ____________________
Witness: ____________________________ Date: ____________________
