Authorization to Release Information
I herby authorize Lone Star College System to conduct a background review of my personal history, including but not limited to, my education, previous employment, driving record, any public records, social security number and previous and current addresses. I understand that this background review may require fingerprinting by a licensed peace officer of the State of Texas and will include a review of any criminal history information maintained by federal, state, county or local criminal justice agencies, courthouses, or criminal record repositories.
I herby authorize any entity, agency or other company to release such information to Lone Star College System upon receipt of this request letter. I understand that the information released is for official use by Lone Star College System. I further understand the information released shall be privileged and confidential, and shall not be released or otherwise disclosed to any other person or agency except under court order.
I hereby release, discharge and hold harmless, Lone Star College System, its Board, officers, employees and agents from any and all liability for any or all claims that arise or may arise as a result of the inspection, investigation, use or preparation of any reports documents or data regarding the review or investigation of my background.
| __________________________________________ |
______________________ |
| Applicant/Volunteer |
Date |
| __________________________________________ |
______________________ |
| Witness |
Date |
__________________________________________
PLEASE PRINT THE FOLLOWING INFORMATION:
| Full Name: |
________________________ |
______________________ |
___________________ |
|
Last |
First |
Middle |
| Social Security Number: |
_______ -_____-_______ |
| Date of Birth: |
______/_____/______ (MM DD YYYY) |
| Driver's License No: |
_______________________ |
State of Issuance: |
_____________________ |
| Have you ever been convicted of, or received deferred adjudication for any violation of criminal law? |
____ yes |
_______ no |
| If yes please describe circumstances__________________________________________________ _______________________________________________________________________________ |
* Ethnicity: ____________________________________________________
( White, African-American (Black), Asian/Pacific Islander, Hispanic, etc.)
*This information is totally voluntary and will be used only for reporting requirements.