Form Pd 407-163 - Request For Applicant'S Employment Record
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2CAS-19
REQUEST FOR APPLICANT’S
EMPLOYMENT RECORD
PD 407-163 (Rev. 02-17)
Date
THIS IS AN INQUIRY CONCERNING:
Exam No.___________
List No._________
Name
Address
Employed By You As
From
To
Social Security No.
Date Of Birth
I hereby give my written consent and request and authorize you to turn over any and all employ-
ment records relating to my employment.
I acknowledge by this authorization that I release you from any obligation or liability in the disclo-
sure of the contents of such fi les and the professional observations or opinions contained therein.
I further request that such records be forwarded to the Police Department Investigator, named
below.
Applicant’s Signature
Social Security Number
The above named person is an applicant for the position of ______________________________
in the Police Department of the City of New York and states that he/she was employed by you in the capac-
ity and for the period(s) shown above.
I have been assigned by the Police Commissioner to investigate the character and record of
this applicant in order to determine his/her eligibility for the position.
You can assist this department in its effort to appoint competent persons of good character
if you will furnish the information requested on the reverse side of this letter. All information will be treated as
confi dential.
Your cooperation and prompt reply will be greatly appreciated.
Rank/Name
Squad No.
E-mail Address
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