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T E M P J A N U A R Y 2 0 2 1
Release of Information Authorization
PLEASE READ CAREFULLY BEFORE SIGNING
I CERTIFY THAT ALL THE INFORMATION ON THIS APPLICATION IS CORRECT AND MAY BE
INVESTIGATED. I understand that falsification, misrepresentation or omission of facts will be cause for denial
of employment or immediate termination of employment regardless of the timing or circumstances of
discovery.
I understand that submission of an application for employment with the Village of Mount Pleasant does not
guarantee employment. I further understand that should an offer of employment be extended by the Village
of Mount Pleasant that such employment is At Will, for no specified duration and may be terminated by either
myself or the Village of Mount Pleasant at any time, with or without reason or notice.
I hereby authorize the Village of Mount Pleasant, its agents, officers or employees to conduct a comprehensive
review of my background. I voluntarily and knowingly authorize any former employer, person, firm,
corporation, organization, school, or government agency, its officers, employees and agents, to release all
information concerning me that said individual, company, firm, corporation or public agency may have, to
include information or data received from other sources, to the Village of Mount Pleasant, its officers,
employees and agents, or any other person or entity making a written or oral request for such information on
behalf of the Village of Mount Pleasant. I understand the information that is sought may include, but is not
necessarily limited to, employment history, drug testing, consumer reports, civil and criminal records, records
from any governmental criminal justice agency, driving records, social security verification and any public
record information. I recognize a copy of this authorization and release is as valid as the original and should
be considered as such.
I voluntarily and knowingly, fully release and discharge, absolve, indemnify and hold harmless the Village of
Mount Pleasant, and such former employer, person, firm, corporation, school or government agency, its
officers, employees and agents from any and all claims, liability, demands, causes of action, damages, or
costs, including attorney’s fees, present or future, whether known or unknown, anticipated or unanticipated,
arising from or incidental to the disclosure or release except for the malicious and willful disclosure of
derogatory facts concerning my employment made for the express purpose of preventing me from obtaining
employment which the officer, employee or agent disclosing such facts knows are untrue.
I further understand that pursuant to the Fair Credit Reporting Act, should the Village of Mount Pleasant or its
agents obtain a consumer credit report as part of the background check, if any adverse action is to be taken
based upon the consumer report, a copy of the report and a summary of the consumer’s rights will be provided
to me.
I understand that any offer of employment is contingent upon successful completion of the background check
and satisfactory completion of a physical examination and drug test.
Applicant’s Printed Name
By clicking the check box I agree to my typed
Signature serving as my written.
Date
Street Name
Apt. #
State
Zip Code
House #
City
Social Security Number
Driver's License Number
Date of Birth
Please save as a PDF and email to individual noted on Job Posting.
