Authorization For Release Of Personal/credit Information And Truthfulness Waiver

Authorization For Release Of Personal/credit Information And Truthfulness Waiver - Aston County Police Page 2

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

PHOTOGRAPH/FINGERPRINT CONSENT FORM

Last_______________________First_________________Middle___________________

Address_________________________________________________________________

Citizenship:___________U.S. Born__________U.S.Naturalized_______________Other

Social Security Number _______- _______- _______ Sex _______ Race ___________

Drivers License Number _________________________ State______________________

Date of Birth _______/______/_____

Place of Birth____________________________

Height: Feet _______________ Inches _______________ Weight ________________

Eye Color: _________________________ Hair Color: ________________________

Home Telephone Number:_________________________________________________

(Area Code) Number

Cellular Telephone Number:_______________________________________________

(Area Code) Number

*E-Mail

Address*:_______________________________________________________

Future correspondence, requiring the completion of additional forms, will be via e-mail

I____________________________________________________, voluntarily consent to

be fingerprinted and photographed by the Gaston County Police Department. I am fully

aware that my photograph and fingerprints will be used for identification purposes during

my background investigation I also realize that if I am hired by the Gaston County

Police Department that the photograph and fingerprints will become part of my personnel

file and if I am not hired the photograph and fingerprints will remain in my background

file until such time that files are destroyed.

This written consent to take, use, and retain in files, photographs and fingerprints of me,

is given voluntarily to the Gaston County Police Department.

__________________________________________/______________

Applicant Signature

Date

Authorization For Release Of Personal/credit Information And Truthfulness Waiver - Aston County Police Page 2