Request For School Records Form
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1
2REQUEST FOR SCHOOL RECORDS
APD – 16
PD 407-169 (Rev. 09-07)
List # ________________
Exam # _______________
Applicant Processing Division
4201 Fourth Avenue
Brooklyn, N.Y. 11232
Date: _________________
_________________________
_________________________
_________________________
To Whom It May Concern:
Pursuant to the written communication below, it is requested that the New York City Police Department be furnished infor-
mation contained in the school records of the student named below who is an applicant for appointment to this Department.
Specifically, it is requested that the information requested on the reverse side of this letter, including any pertinent comments
from former teachers or other school personnel, be furnished as it appears on your records.
Your prompt attention to this matter will be appreciated.
Sincerely,
__________________________________
Investigator, Squad #
AUTHORIZATION
I hereby authorize the release of any and all information contained in my school records or known to school personnel and
that such information and/or records be disclosed, furnished to, and/or examined by the New York City Police Department
for the purpose of determining my eligibility for appointment to the New York City Police Department. This Authorization shall
remain in effect until canceled by me in writing.
I acknowledge by this authorization that I release you from any obligation or liability in the disclosure of the contents of such
files and the professional observations or opinions contained therein.
_________________________________________
_____________________________________________
Full Name – Printed
Candidate’s Signature
Date Of Birth: ______________________________
Attended School From: ______________________
To: ______________________
Social Security Number: _____________ – _________ – ______________
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