Carroll Police Department
68 Center St - Carroll, OH 43112 Telephone (740) 756-9141 - Fax (740) 756-4611
Authority for Release of Information Fill in this page by hand on the printed copy.
Last Name First Name Full Middle Name
Home Address City State Zip
Date of Birth (Month/Day/Year ) Sex Race Social Security Number Drivers License Number and State
I hereby authorize any commissioned agent or representative of the Carroll Police Department, bearing this release, or a copy thereof, within one year of its date, to obtain any information in your files pertaining to my criminal, driving, employment, credit or educational records, including, but not limited to, academic, achievement, attendance, athletic, personal history, and disciplinary records, military records, medical records, and credit records. I hereby direct you to release such information upon request of the bearer.
This request is executed with full knowledge and understanding that the information is for the official use of the Carroll Police Department. Consent is granted for the Carroll Police Department to furnish such information, as is described above, to third parties in the course of fulfilling its official responsibilities.
I hereby release you, as the custodian of such records, and any school, college, university, or other educational institution, hospital, or other repository of medical records, military records, credit bureau, lending institution, consumer reporting agency, police departments or retail business establishments including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. Should there be any question as to the validity of this release, you may contact me as indicated below.
MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
Subscribed and sworn before me this day of
, 20
Notary signature