AUTHORIZATION TO RELEASE INFORMATION,                             5122F

INCLUDING CONSENT TO FINGERPRINT BACKGROUND CHECK

 

To Whom It May Concern:

              I, ______________________________, am an employee of the District, am seeking employment, volunteer assignment, and/or approval to be selected as an on-call substitute with Cut Bank School District (the District). I hereby expressly authorize release of any and all information of a confidential or privileged nature, including confidential criminal justice information as defined in § 44-5-103(3), MCA, to the staff of the District and its agents.  I will provide a set of fingerprints, and understand that a fingerprint background check will be at my expense and will be deducted from the initial paycheck, unless other arrangements are made with the District Office.

              I c have  c have not [check one] been convicted or adjudicated* of any crime in any jurisdiction, besides minor traffic offenses. Attached, if necessary, is a complete description of the circumstances surrounding the crime(s) of which I have been convicted or adjudicated in any jurisdiction. I acknowledged that I have the right to obtain a copy of the fingerprint background check obtained by the District and to challenge its accuracy if necessary. I further acknowledge that my access to children may be denied prior to completion of the fingerprint background check.           * Adjudication – A passing of judgment of a court of law or a decision of a judge.

              I hereby release the District and any organization, company, institution, or person furnishing information to the District and its agents as expressly authorized above, from any liability for damages which may result from any dissemination of the information requested, subject to provisions of Title 44, Chapter 5, Part 3, MCA.

              All statements and information provided within this application and attachments, if any, are true and complete. I understand that omission or misrepresentation of material fact may result in refusal of or suspension from employment.

              This document is effective until revoked in writing by me.

 

_______________________________________        ______                            _____________________

SIGNATURE                                                                                         DATE

 

Print full name: _____________________________________________________________________

 

Print full address: ____________________________________________________________________

                                          STREET                                         CITY                                 STATE   ZIP

Birth Date: __________________        Social Security Number: ________________________________

 

STATE OF MONTANA             )

                                                        : ss.

County of _______________   )

 

              On this ______ day of _______________, 20___, before me, a Notary Public for the state of Montana, personally appeared ______________________________, known to me to be the person named in the foregoing Authorization to Release Information, and acknowledged to me that _______ executed the same as _______ free act and deed for the purposes therein mentioned.

              IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal the day and year in this certificate first above written.

 

                                                                                    ____________________________________

                                                                                    ______________________________[name]

              (   S E A L   )                                               NOTARY PUBLIC for the state of Montana

                                                                                    Residing at __________________, Montana

                                                                                    My commission expires:  _______________