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WE ARE AN EQUAL OPPORTUNITY EMPLOYER. WE DO NOT EXCLUDE APPLICANTS ON THE BASIS OF RACE, COLOR RELIGION, GENDER, NATIONAL ORIGIN, DISABILITIES OR OTHER PROTECTED STATUSES AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION I, an applicant for employment with the City of Burley, do hereby authorize a review of and full disclosure of all records or information concerning myself to any duly authorize agent of the City of Burley, whether the said records are of a public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of all records and information of educational institutions; employment and pre-employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me, either criminal or civil, in which I have, or have had any interest or involvement. I understand that any information obtained during any personal history background investigation which is developed directly or indirectly, in whole or in part, upon this authorization will be considered in determining my suitability for employment by the City of Burley. I hereby agree that any person(s) or entities who may furnish such information concerning me shall not be held liable for providing this information; and I do hereby release said person(s) and entities from any and all liability which may be incurred as a result of furnishing such information. I further authorize that a photocopy of this signed release form will be valid as an original thereof, even though the said photocopy does not contain an original writing of my signature. DATED: Printed Name, including all names I have previously used or been known by: SIGN