Request For Certificate Of Dispositions (Page 3 of 3) in pdf

Request For Certificate Of Dispositions Page 3

VILLAGE OF PORT CHESTER

Justice Court

350 No. Main Street, Port Chester, New York 10573

(914) 939-8220  Fax: (914) 939-3479

Peter F. Sisca, Village Justice

Regina Hill, Court Clerk

Matthew J. Troy III, Acting Village Justice

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION

I__________________________, do hereby authorize a review of and full disclosure of

all records concerning myself whether the said records are public, private or of

confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of

records of any arrests or convictions against me in the Justice Court, Village of Port

Chester, New York.

I certify that the Court Clerk who may furnish such information concerning me shall not

be held accountable for giving this information and I do hereby release said person from

any and all liability which may be incurred as a result of furnishing such information. I

further release the Justice Court from any and all liability which may be incurred as a

result of collecting such information.

I have read and have had read to me the contents of this “Authorization for Release of

Personal Information” and fully understand it.

_______________________________

____________________

Signature of Individual

Date and Time

Sworn to before me this ____________ day of _____________, 20_____

______________________________

Notary Public

Request For Certificate Of Dispositions Page 3