Employment Interest Form - Winthrop Harbor Police (Page 2 of 2) in pdf

Employment Interest Form - Winthrop Harbor Police Page 2

AUTHORITY TO RELEASE INFORMATION

Having expressed interest in employment with the Winthrop Harbor Police Department, and

desiring that they be informed of my previous records and character, I hereby authorize an

investigation into all records which may be of interest to them. This authorization to release

information includes, but is not limited to; school, employment, military, criminal, court and

driving records, whether privileged or not. This authorization to release information is executed

in context of the Village of Winthrop Harbor Police Department giving consideration to my

interest in employment, and shall serve as a release of all liability to all parties furnishing such

information to the Village of Winthrop Harbor and/or its Departments.

Once signed and Notarized, a copy or facsimile of this Authority to Release Information form

shall serve as providing the same authority to release information as the original document.

** SIGNATURE MUST BE WITNESSED BY A NOTARY PUBLIC **

Applicant Name: (print) _______________________________

Applicant Signature: _________________________________

Address: __________________________________________

City: ________________________ State: ___ Zip: _________

(This section to be completed by a Notary Public)

SUBSCRIBED AND SWORN TO before me this _____ day of _____________, 20__.

Notary Public Signature _________________________

(notary seal)

THIS FORM MUST BE SIGNED, NOTARIZED AND SUBMITTED WITH THE EMPLOYMENT

INTEREST FORM AND A COPY OF YOUR DRIVER’S LICENSE.

Page 2 of 2

Employment Interest Form – Revised 2/2/2016

Employment Interest Form - Winthrop Harbor Police Page 2