AUTHORIZATION TO RELEASE INFORMATION

TO: ___________________________

I hereby request and authorize you to furnish the Morrow Emergency Communications and/or Morrow Police Department with any and all information they may request concerning my work record, educational history, military record, financial status, criminal record, general reputation, and past or present medical condition. This authorization is specifically intended to include any and all documents of the confidential or privilege nature as well as photocopies of such documents, if requested. The information will be used for the purpose of determining my eligibility for employment as a law enforcement officer.

I hereby release you and your organization from any liability which my or could result from furnishing the information requested above or from any subsequent use of such information in determining my qualifications to serve as a law enforcement officer. This release will expire 90 days after the date signed.

Signature _________________________________

Date _________________________________

State of ___________

County of ____________

On __________, 20____, ____________________ personally appeared before me,

________Who is personally known to me

________Whose identity I proved on the basis of ___________________

________Whose identity I proved on the oath/affirmation of

                  _________________________, a credible witness

to be the signer of the above instrument, and he/she acknowledge that he/she signed it.

                                                                        _________________________________

                                                                        Notary Public

                                                                        My commission expires______________