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w LE AUTHORITY FOR .RELEASE
<br />Florida Department of OF INFORMATION
<br />La'"' Enforcement (Background Investigation Waiver)
<br />Incorporated by Reference in -Rule 11B -27,0022(2)(a), FAC.
<br />To: Concerned Person or Authorized APPLICANT'S NAME:
<br />Representative of Any Organization,
<br />Institution or Repository of Records DATE OF BIRTH:
<br />LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER:
<br />AGENCY REQUESTING BACKGROUND INFORMATION:
<br />ADDRESS:
<br />CJSTC
<br />58
<br />Having made application for certification or employment as a law enforcement, correctional, or correctional probation officer within the state of Florida, I hereby authorize for
<br />one year, from the date of execution hereof, any authorized representative of a. Florida criminal justice agency or Regional Criminal Justice -Selection Center bearing this
<br />release to obtain any Information pertaining to my employment, credit history, education, residence, academic achievement, personal information, work performance,
<br />background investigations, polygraph examinations, any and all internal affairs investigations or disciplinary records, Including any files that are deemed to be confidential
<br />and/or sealed.
<br />I also authorize release of any criminal justice records of arrests; citations, detentions, probation and parole recordsi or any -police reports or other police records in which I
<br />may be named for any reason, Including any files that are deemed to be juvenile and confidential..I hereby direct you to release this information upon the request of the
<br />bearer, whether in person or by correspondence. I further authorize the bearer to make copies of these records.
<br />This release Is executed with the full knowledge and understanding that these records and informafion are for the official use of a Florida criminal justice agency or Regional
<br />Criminal Justice Selection Center in fulfilling official responsibilities, which may include sharing the records or information with other criminal justice agencies, .Regional
<br />Criminal Justice Selection Centers or the State of Florida or release.to third parties as may be required by Florida public records laws. I hereby release you, as the custodian of
<br />such records, and employer, educational Institution, physician, hospital or other repository of medical records, credit bureau or consumer repotting .agency, including its officers,
<br />employees, and related personnel, both Individually, and collectively, from any and all Debility for damages of whatever kind, which may at any time result to me, my heirs, family or
<br />associates because of compliance with this authorization and request to release Information, or any attempt to comply It. A copy of this form w1N be as effective as the original.
<br />I hereby authorize the National Records Center, St. Louis, Missouri, or other custodian of my military. record to release Information or copies from my military personnel and related
<br />medical records, including a copy of my DD 214, Report of Separation, or other official documents from the United. States Military denoting discharge status or current
<br />status to: active Military
<br />Section 768.095, RS., tined Employer Immunity from. Liability; disclosure of trhformation regarding former or current employees states: An employer:who discloses informadon.about a
<br />former or current employee to a prospective employer of the former or current employee upon request of the:.prospecil" employer or of the iorneror current employee, is Immune from
<br />civil liability for such disclosure of its consequences, unless it `shown by dear and:convincing evidence. that the information disclosed by the former occurrent employer waslmowingly
<br />false or violated any civil right of the former or current employee protected under chapter 760; Florida Statutes. Pursuant to :Sedlons 943:f34(2)(a) and (n, f S, Chapter20@f-94;
<br />Laws, of Florida, disclosure of Information Is required unless contrary to state or federal law. Civil penalties may be available for refusal to disclose non -privileged /egafty
<br />obtainable Information.
<br />Applicants. Signature Date
<br />Applicant's Address
<br />OATH
<br />Pursuant.to Section 117.05(131(a}, Florida Statutes
<br />STATE OF COUNTY OF
<br />Sworn to (or affirmed) and. subscribed before me this
<br />day of year ___.,.By
<br />Signature of Notary Public — State of Florida
<br />Print, Type, or Stamp Commissioned name of Notary Public
<br />Personally Known ❑ OR Produced Identification ❑
<br />Type of identification Produced
<br />Effective: 8/912001 Pursuant to Original— Employing Agency 1 of 1 CommissiomApproved Revisions: 12116110
<br />Sections 943.134(2)(a) and (4), F.S. Form Effective Date: 312013 .
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