Authorization For Release Of Information Form printable pdf download

AUTHORI ZATI ON FOR RELEASE OF I NFORM ATI ON

I , ________________________________________________________________________________________________

NAM E (M UST BE PRI NTED-LEGI BLY)

(SSN)

(DOB)

PURSUANT TO NM SA 1978, SECTION 29-10-6(A) (Repl. Pamp. 1990), OF THE NEW M EXICO ARREST RECORD

I NFORM ATI ON ACT, HEREBY APPOI NT:

NAM E (M UST BE PRI NTED)

(I F NO AGENT, PRI NT "SELF")

ADDRESS: _______________________________________________________________________________________

AS AN AUTHORI ZED AGENT FOR M E FOR THE PURPOSE OF INSPECTING (AND /OR OBTAINING COPIES

OF) ANY NEW M EXI CO ARREST FI NGERPRI NT CARD SUPPORTED ARREST RECORD I NFORM ATI ON

M AI NTAI NED BY THE DEPARTM ENT OF PUBLI C SAFETY, I NCLUDI NG I NFORM ATI ON CONCERNI NG

FELONY OR M ISDEM EANOR ARRESTS AND INFORM ATION OBTAINED FROM RELEVANT FINGERPRINT

DATABASES.

TO THE CUSTODI AN OF THE RECORDS I N QUESTI ON, I HEREBY DI RECT YOU TO RELEASE SUCH

I NFORM ATI ON TO THE AUTHORI ZED AGENT AS DESCRI BED ABOVE.

I HEREBY RELEASE THE CUSTODIAN OR CUSTODIANS OF SUCH RECORDS AND THE DEPARTM ENT OF

PUBLI C SAFETY, I NCLUDI NG ANY OF THEI R AGENTS, EM PLOYEES, OR REPRESENTATI VES I N ANY

CAPACITY, FROM ANY AND ALL CLAIM S OF LIABILITY OR DAM AGE OF WHATEVER KIND OR NATURE,

WHI CH AT ANY TI M E COULD RESULT TO M E, M Y HEI RS, ASSI GNS, ASSOCI ATES, PERSONAL

REPRESENTATI VE OR REPRESENTATI VES OF ANY NATURE BECAUSE OF COM PLI ANCE BY SAI D

CUSTODI AN OR CUSTODI ANS WI TH THI S "AUTHORI ZATI ON FOR RELEASE OF I NFORM ATI ON" AND

M Y REQUEST CONTAINED HEREIN FOR THIS RELEASE OR BECAUSE OF ANY USE OF THESE RECORDS.

THI S RELEASE I S BI NDI NG, NOW AND I N THE FUTURE AND IS VALID FOR A PERIOD OF UP TO 120 DAYS

FROM THE DATE SI GNED, ON M Y HEI RS, ASSI GNS, ASSOCI ATES, PERSONAL REPRESENTATI VE OR

REPRESENTATI VES OF ANY NATURE

APPLI CANT SI GNATURE: ________________________________________

DATE: ________________________________________

(* ATTN: NOTARY-ENSURE DOCUM ENT I S SI GNED BY BOTH APPLI CANT AND PARENT (GUARDI AN)

I N YOUR PRESENCE AND NAM E, DOB, SOC I NFO I S VERI FI ED WI TH A VALI D I D)

SUBSCRI BED AND SWORN TO BEFORE M E THI S _______ DAY OF ____________________,20 ___________.

___________________________________________

(NOTARY PUBLI C)

M Y COM M I SSI ON EXPI RES: _____________________.

Authorization For Release Of Information Form