Oklahoma Pardon And Parole Board Commutation Application (Page 17 of 18) in pdf

Oklahoma Pardon And Parole Board Commutation Application Page 17

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information, then complete and sign in ink (blue

or black).

I authorize any duly accredited representative of the Oklahoma Pardon and Parole Board and/or the

Oklahoma Department of Corrections, to obtain any information relating to my activities from schools,

residential management agents, employers, criminal justice agencies, retail business establishments,

courts, or other sources of information. This information may include, but is not limited to, my

academic, residential, achievement, performance, attendance, disciplinary, employment history,

criminal history, arrest, conviction, including the pre-sentence investigation report, if any, medical,

psychiatric/psychological, health care, financial, and credit information.

I understand that, for financial or lending institutions and certain other sources of information, a

separate specific release may be needed (pursuant to their request or as may be required by law), and I

may be contacted for such a release at a later date.

I further authorize the Oklahoma Pardon and Parole Board and/or the Oklahoma Department of

Corrections, or any other authorized state agency, to request criminal record information about me

from criminal justice agencies for the purpose of determining my suitability for a commutation.

I authorize custodians of records and sources of information pertaining to me to release such

information upon request of any duly accredited representative of the Oklahoma Pardon and Parole

Board and/or the Oklahoma Department of Corrections or any state agency authorized above regardless

of any previous agreement to the contrary. I understand that the information released by records

custodians and sources of information is for official use by the State of Oklahoma only for the purposes

of processing my application for a commutation, and may be re-disclosed by the State of Oklahoma

only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed by me.

This authorization is valid for one (1) year from the date signed.

_____________________________

Full name (Typed or Printed)

_____________________________

Signature of Applicant

____________________________

Date Signed

Oklahoma Pardon and Parole Board Commutation Application Revised March 2017

Oklahoma Pardon And Parole Board Commutation Application Page 17