"Authorization for Release of Personal Information Form (Miscellaneous 3)" - New York City

Authorization for Release of Personal Information Form (Miscellaneous 3) is a legal document that was released by the New York City Department of Correction - a government authority operating within New York City.

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Download "Authorization for Release of Personal Information Form (Miscellaneous 3)" - New York City

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AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I,
, do hereby authorize a review of and full disclosure of
all records concerning myself to the New York City Department of Correction, whether the said records are of a
public, private or confidential nature.
The intent of this authorization is to give my full and complete disclosure of records educational institutions;
financial or credit institutions, including records of loans, the records of commercial or detail credit agencies
(including credit reports and/or ratings); and other financial statements records wherever files; medical and
psychiatric treatment and/or consultation, including hospitals, clinics, private practitioners, and the U.S. Veterans
Administration; employment and pre-employment records including background reports, efficiency ratings,
complaints of grievances filed by or other counsel whether representing me or another person in any case, either
criminal or civil, in which I presently have, or have had an interest in.
I understand that any information obtained by a personal history background investigation, which I developed
directly or indirectly, in whole or in part, upon this release the City of New York Department of Correction will
consider authorization in determining my suitability for employment.
I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for
giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a
result of furnishing such information. I further release the Department of Correction from any and all liability that
may be incurred as a result of collecting such information.
A PHOTOCOPY OF THIS RELEASE WILL BE VALID AS AN ORIGINAL THEREOF,
EVEN THOUGH THE SAID PHOTOCOPY DOES NOT CONTAIN AN ORIGINAL WRITING OF MY SIGNATURE.
I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS “AUTHORIZATION FOR RELEASE OF
MY PERSONAL INFORMATION”.
________________________
______________________________
DATE
SIGNATURE OF APPLICANT
Print Name
___________
_________
EXAM NO.
LIST NO.
DATE OF BIRTH
SOCIAL SECURITY NUMBER
________________________________
Investigator
Miscellaneous 3
N.Y.C. DEPARTMENT OF CORRECTION * APPLICANT INVESTIGATION UNIT * 75-20 Astoria Blvd. East Elmhurst, NY 11370
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
I,
, do hereby authorize a review of and full disclosure of
all records concerning myself to the New York City Department of Correction, whether the said records are of a
public, private or confidential nature.
The intent of this authorization is to give my full and complete disclosure of records educational institutions;
financial or credit institutions, including records of loans, the records of commercial or detail credit agencies
(including credit reports and/or ratings); and other financial statements records wherever files; medical and
psychiatric treatment and/or consultation, including hospitals, clinics, private practitioners, and the U.S. Veterans
Administration; employment and pre-employment records including background reports, efficiency ratings,
complaints of grievances filed by or other counsel whether representing me or another person in any case, either
criminal or civil, in which I presently have, or have had an interest in.
I understand that any information obtained by a personal history background investigation, which I developed
directly or indirectly, in whole or in part, upon this release the City of New York Department of Correction will
consider authorization in determining my suitability for employment.
I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for
giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a
result of furnishing such information. I further release the Department of Correction from any and all liability that
may be incurred as a result of collecting such information.
A PHOTOCOPY OF THIS RELEASE WILL BE VALID AS AN ORIGINAL THEREOF,
EVEN THOUGH THE SAID PHOTOCOPY DOES NOT CONTAIN AN ORIGINAL WRITING OF MY SIGNATURE.
I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THIS “AUTHORIZATION FOR RELEASE OF
MY PERSONAL INFORMATION”.
________________________
______________________________
DATE
SIGNATURE OF APPLICANT
Print Name
___________
_________
EXAM NO.
LIST NO.
DATE OF BIRTH
SOCIAL SECURITY NUMBER
________________________________
Investigator
Miscellaneous 3
N.Y.C. DEPARTMENT OF CORRECTION * APPLICANT INVESTIGATION UNIT * 75-20 Astoria Blvd. East Elmhurst, NY 11370