spdrelease12.20
SMITHFIELD POLICE DEPARTMENT
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I, ____________________________________, do hereby authorize a review of and full disclosure of all
records, or any part thereof, concerning myself, by and to the Chief of Police of the Town of Smithfield, or their
designee of the Town of Smithfield Police Department, or the Director of Human Resources of the Town of
Smithfield, whether the 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 deposits, withdrawals and balances
of checking and savings accounts and loans, and also the records of commercial or retail credit agencies
(including credit reports and/or ratings), medical and psychiatric treatment and/or consultation, including
hospitals, clinics, private practitioners, and the U.S. Veterans Administration, public utility companies,
employment and pre-employment records including background reports, polygraph reports, efficiency ratings,
complaints or grievances filed by or against me, and salary records, real and personal property tax statements
and records, and other financial statements and records wherever filed; records of complaint, arrest, trial and/or
convictions for alleged or actual violations of law, including criminal and/or traffic records; records of
complaints of a civil nature made by or against me, wheresoever located and to include the records and
collections of attorneys at law, or of other counsel, whether representing me or another person in any case in
which I presently have or have had an interest.
I reiterate and emphasize that the intent of this authorization is to provide full and free access to the background
and history of my personal life, for the specific purpose of pursuing a background investigation which may
provide pertinent data for the Town of Smithfield Police Department to consider in determining my suitability
for employment by that department.
It is my specific intent to provide access to personal information, however personal or confidential it may
appear to be, and the sources of information specifically enumerated above is not intended to deny access to any
records not specifically identified herein.
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 will be considered in determining my
suitability for employment by the Town of Smithfield Police Department.
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.
Signature Date Date of birth / / .
Street Address
City, State, Zip Code
State of County of
The foregoing instrument was acknowledged before me this day of 20
My Commission Expires (Signature of Notary)
