Form DPS-249-C "Authorization for Release of Personal Information" - Connecticut

What Is Form DPS-249-C?

This is a legal form that was released by the Connecticut Department of Emergency Services and Public Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2011;
  • The latest edition provided by the Connecticut Department of Emergency Services and Public Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DPS-249-C by clicking the link below or browse more documents and templates provided by the Connecticut Department of Emergency Services and Public Protection.

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Download Form DPS-249-C "Authorization for Release of Personal Information" - Connecticut

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STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES
&
PUBLIC PROTECTION
SPECIAL LICENSING AND FIREARMS UNIT
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, a duly authorized agent of the State of Connecticut, Department of Emergency Services
and Public Protection, Division of State Police, Special Licensing & Firearms Unit, whether said records are of a public, private
or confidential nature.
The intent of this authorization is to give my consent for a full and complete disclosure of the records of educational institutions,
financial or credit institutions, including records or deposits, withdrawals and balances of checking and savings accounts and
loans, and also the records of the intent of this authorization is to give my consent for full and complete disclosure of the records
of educational, commercial or retail credit agencies (including credit reports and/or), medical and psychiatric treatment and/or
consultation, including hospitals, clinics, private practitioners and the U.S. Veteran’s Administration, public utilities, employment
and pre-employment records, including background reports, sufficiency ratings, real and personal property tax statements and
records wherever filed, conviction records for violation of the law, including criminal and or traffic records, records of complaint of
a civil nature made by or against me, wheresoever located, and to include the records and recollection of attorney-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.
It is the intent of this authorization to provide full and free access to background and history of my personal life, for the specific
purpose of pursuing a background investigation, which may provide pertinent data for the Connecticut State Police, Special
Licensing & Firearms Unit, to consider in determining my suitability for licensing 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 about are not intended to deny access to any records not specifically mentioned herein.
I understand that any information obtained by the 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 a permit by the
Special Licensing & Firearms Unit. I fully understand that refusal to grant this authorization will not, or itself; constitute a basis
for rejection of my application.
A photocopy of this release will be valid as an original hereof, even though the said photocopy does not contain an original
writing of my signature.
__________________________________
_________________
__________________________
Signature
Date of Birth
Social Security # (Optional)
_____________________________________________________________________________________________________________
Address, City, State, ZIP
STATE OF ______________________________
SS
COUNTY OF ____________________________, TOWN __________________________
Personally appeared___________________________________________, signer of the foregoing written authorization for
release of personal information and made oath to the truth of the matters contained therein, before me.
_______________________________________________
NOTARY PUBLIC, JUSTICE OF THE PEACE
OR COMMISSIONER OF SUPERIOR COURT
MY COMMISION EXPIRES: ________________________
DPS-249-C (Rev. 7/11)
STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES
&
PUBLIC PROTECTION
SPECIAL LICENSING AND FIREARMS UNIT
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, a duly authorized agent of the State of Connecticut, Department of Emergency Services
and Public Protection, Division of State Police, Special Licensing & Firearms Unit, whether said records are of a public, private
or confidential nature.
The intent of this authorization is to give my consent for a full and complete disclosure of the records of educational institutions,
financial or credit institutions, including records or deposits, withdrawals and balances of checking and savings accounts and
loans, and also the records of the intent of this authorization is to give my consent for full and complete disclosure of the records
of educational, commercial or retail credit agencies (including credit reports and/or), medical and psychiatric treatment and/or
consultation, including hospitals, clinics, private practitioners and the U.S. Veteran’s Administration, public utilities, employment
and pre-employment records, including background reports, sufficiency ratings, real and personal property tax statements and
records wherever filed, conviction records for violation of the law, including criminal and or traffic records, records of complaint of
a civil nature made by or against me, wheresoever located, and to include the records and recollection of attorney-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.
It is the intent of this authorization to provide full and free access to background and history of my personal life, for the specific
purpose of pursuing a background investigation, which may provide pertinent data for the Connecticut State Police, Special
Licensing & Firearms Unit, to consider in determining my suitability for licensing 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 about are not intended to deny access to any records not specifically mentioned herein.
I understand that any information obtained by the 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 a permit by the
Special Licensing & Firearms Unit. I fully understand that refusal to grant this authorization will not, or itself; constitute a basis
for rejection of my application.
A photocopy of this release will be valid as an original hereof, even though the said photocopy does not contain an original
writing of my signature.
__________________________________
_________________
__________________________
Signature
Date of Birth
Social Security # (Optional)
_____________________________________________________________________________________________________________
Address, City, State, ZIP
STATE OF ______________________________
SS
COUNTY OF ____________________________, TOWN __________________________
Personally appeared___________________________________________, signer of the foregoing written authorization for
release of personal information and made oath to the truth of the matters contained therein, before me.
_______________________________________________
NOTARY PUBLIC, JUSTICE OF THE PEACE
OR COMMISSIONER OF SUPERIOR COURT
MY COMMISION EXPIRES: ________________________
DPS-249-C (Rev. 7/11)