BOARD OF EXAMINERS OF COURT REPORTERS OF THE STATE OF KANSAS
AUTHORIZATION AND RELEASE
I, , born at ,
, on ,
(State) (Date of Birth)
having filed an application for certification as a court reporter in the State of Kansas, hereby consent to have an
investigation made as to my moral character, professional reputation, and fitness for certification by the
Supreme Court as a court reporter in the State of Kansas, all of which will be reported only to the Board of
Examiners of Court Reporters of the State of Kansas. I agree to give any further information which may be
required in reference to my past record. I understand that the contents of my character report are confidential.
I hereby authorize and request every educational, or other institution, hospital, or other medical facility,
physician, person, firm, company, corporation, governmental agency, police authority, court, association or
institution having control of any documents, records and other information requested by the Board of Examiners
of Court Reporters of the State of Kansas to furnish to them such information or records, including documents,
certification files, medical records and physician’s reports, credit history reports, all criminal history records,
and any other pertinent data so requested, and to permit them or any of their agents or representatives to inspect
and make copies of such documents, records, and other information.
I hereby authorize the National Personnel Records Center, St. Louis, Missouri, or other custodian of my military
record to release to the Board of Examiners of Court Reporters of the State of Kansas any requested information
or photo copies from my military personnel and related medical records. This could include a photocopy of my
DD form 214, Report of Separation. My serial number and branch of the military were:
I hereby release, discharge and exonerate the Board of Examiners of Court Reporters of the State of Kansas,
their agents and representatives, and any party furnishing information from liability arising out of the
furnishing or inspection of such documents, records, and other information or the investigation made by the
Board of Examiners of Court Reporters of the State of Kansas.
I hereby acknowledge that I am executing this document and do hereby authorize that it may be copied by the
Board of Examiners of Court Reporters of the State of Kansas and that said copies may be used and accepted as
originals in the same manner and for the same purpose as if they were the original of this document.
I have read the foregoing document and have answered all questions. The answers are complete and truthful of
my own knowledge.
Signature of Applicant (SIGN IN BLUE INK)
STATE OF )
COUNTY OF )
Subscribed and sworn to before me this day of , 20 .
Notary Public (SIGN IN BLUE INK)
My Commission expires: