UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
AUTHORIZATION FOR RELEASE OF INFORMATION
Carefully read this authorization to release information about you, then sign and date it in ink.
I Authorize any investigator, special agent, or other duly accredited representative of the
authorized Federal agency conducting my background check, to request criminal record
information about me from criminal justice agencies for the purpose of determining my
eligibility for access to confidential information.
I Authorize the Federal agency conducting my investigation to disclose the record of my
background investigation to the requesting agency for the purpose of making a determination of
I Understand that the information released by records custodians and sources of information is
for official use by the Federal Government, and that it may be re-disclosed by the Government
only as authorized by law.
Copies of this authorization that show my signature are as valid as the original release signed by
This authorization is valid for two (2) years from the date signed or upon the termination of my
affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink) Full Name (Type or Print Legibly)
Social Security Number
Current Address (Street, City, State, Zip Code)
Home Phone Number