State Form 49698-Authority To Release Information
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1INDIANA PRIVATE DETECTIVE LICENSING BOARD
AUTHORITY TO RELEASE INFORMATION
INDIANA PROFESSIONAL LICENSING AGENCY
State Form 49698 (4-00)
INDIANA GOVERNMENT CENTER SOUTH
302 W. WASHINGTON STREET, ROOM E034
INDIANAPOLIS, INDIANA 46204
I, ____________________________________________________________ having made application for licensing with the Private Detective
Licensing Board and desiring that they be informed of my personal records pertinent to their investigation, hereby authorize an investigation
into all records which may be of interest to them. This authorization includes, but is not limited to medical, school, credit, arrest and
employment records, whether privileged or not. This authorization to furnish information is executed in consideration of the Private Detective
Licensing Board giving my license application consideration and shall serve as a release of all liability to all parties furnishing such information
to the Private Detective Licensing Board and their authorized agents.
A photocopy of this release shall be considered as effective and binding as the original copy.
Signature of applicant
STATE OF _________________________________)
COUNTY OF _______________________________)
Subscribed and sworn to before me this ___________________________________________________day
of ______________________________________________, _______________.
Signature of Notary
Printed name of Notary
Date commission expires (month, day, year)
County of residence of notary
NOTARY SEAL
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Parent category: Business