Consent For Release Of Information - Alaska Comission On Postsecondary Education
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1Consent for Release of Information
Alaska Performance Scholarship Program Participation Agreement
Instructions: This form must be filled out and submitted for all owners and senior administrative officials. NOTE: A photocopy of this
release is to be honored as if it were an original.
(Complete Name)
I,
hereby authorize the Alaska Commission on
Postsecondary Education (ACPE) and/or its agents to obtain a credit report and make an independent investigation of my background,
references, character, criminal, or police records, including those maintained by both public and private organizations and all public
records for the purpose of confirming evidence of satisfactory reputation of business and professional integrity.
As an owner or a senior official of:
(Name of Institution/Corporation)
I release ACPE or its agents and any person or entity, which provides information pursuant to this authorization, from any and all
liabilities, claims, or lawsuits relative to the information obtained from any and all of the above referenced sources used.
1. Personal Information
First Name:
Middle Name:
Last Name:
Maiden Name or Other Names Used:
Date of Birth:
SSN:
Driver's License #:
State:
2. Address Information
Present Street Address:
How long?
City:
State:
Zip:
Former Street Address:
How long?
City:
State:
Zip:
3. Contact Information
E-mail Address:
Phone Number:
Certification
I certify that all information provided is true and correct to the best of my knowledge. I release ACPE or its agents and any person or
entity, which provides information pursuant to this authorization, from any and all liabilities, claims, or lawsuits in regards to the
information obtained from any and all of the above referenced sources used.
Signature:
Date:
APS PPA: Consent for Release of Information (Rev. 6/14)
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