Authorization For Release Of Personal/credit Information And Truthfulness Waiver - Aston County Police

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GASTON COUNTY POLICE
MAILING ADDRESS : P.O. BOX 1578 GASTONIA, N.C. 28053-1578
STREET ADDRESS : 128 WEST MAIN AVE., GASTONIA, N.C. 28052
TELEPHONE NUMBER : (704) 866-3193 FAX NUMBER (704) 862-5727
AUTHORIZATION FOR RELEASE OF PERSONAL/CREDIT INFORMATION
AND TRUTHFULNESS WAIVER
I, _____________________________________________________, do hereby authorize a review of and
full disclosure of all records concerning myself to any authorized agent of the Gaston County Police
Department, whether the said records are of a public, private, medical, educational or confidential nature,
including on-line social networking sites.
I understand that this authorization is to give my consent for full and complete disclosure of whatever
information is deemed necessary in the course of a background investigation to determine my suitability for
a position with Gaston County. I further understand that the background investigation will be conducted in
accordance with the guidelines as prescribed by the North Carolina Criminal Justice Training and
Standards Council.
Further, I fully understand that, pursuant to the provisions of the Privacy Act of 1974, I am not required to
give my consent or sign this waiver and release form. However, in consideration of and as an inducement
for the persons or organizations to release to the Gaston County Police Department the requested
information, I hereby agree and promise to indemnify and forever save harmless, both parties, its officers,
agent, servants or employees from and against any and all liabilities, claims, demands, damages, expenses,
fees, fines, penalties, suits, proceedings, actions, including attorney’s fees of any kind and nature arising or
growing out of or in anyway connected with the disclosure of the requested information.
In conjunction with my application for employment with the Gaston County Police Department, I give
consent for a departmental investigator to obtain a copy of my consumer credit report. I also give consent
for this consumer credit report to be reviewed and considered, in part or in whole by departmental
personnel for the purpose of determining my suitability for employment.
In addition you will be required to provide truthful responses during the application and hiring process.
Providing false or misleading information shall be sufficient cause for rejection or dismissal, now or at
anytime in the future you are employed with us. I hereby certify I have read and fully understand the above
statement and agree to be honest and truthful.
I further agree and stipulate that a copy of this waiver and release shall have the same force and effect as
the original thereof.
____________________________________
FULL SIGNATURE (Includes Maiden)
SWORN AND SUBSCRIBED BEFORE ME
____________________________________
ADDRESS
This ______ day of ______________, 20_____
___________________________________
CITY, STATE & ZIP CODE
_______________________________________
NOTARY PUBLIC
___________________________________
DATE OF BIRTH
_______________________________________
MY COMMISSION EXPIRES:
___________________________________
SOCIAL SECURITY NUMBER

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