CONSENT TO RELEASE INFORMATION RELEASE FROM LIABILITY TO WHOM IT CONCERN: I am an applicant for a position with the (Port District of South Whidbey Island). The Port needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I have applied. I have authorized PDSWI to gather all available information regarding my employment background and personal history and other information which may be of a confidential or privileged nature. I, the undersigned, authorize you to furnish PDSWI any and all information that you have concerning me, including without limitation my work record, my background and reputation, my criminal history; including any arrest records and any information contained in investigative files, and any other personal records, including medical, psychological, military service or financial matters. Information of a confidential or privileged nature may be included in the materials you provide to PDSWI. I further specifically consent to the Washington Department of Revenue’s release of any tax returns, as defined by RCW, filed by, on behalf of; or with respect to me, and any tax information, as defined by RCW, that pertains to me. I request your cooperation in supplying this information to PDSWI in response to a request from that office. I hereby agree to release you and those who supplied you with the above information, your company or organization, and the Port District of South Whidbey Island, its Directors, employees and or agents, from any liability for any damage with may result from furnishing the requested information. Applicant’s Signature date Driver’s License # (please include !) Applicant’s printed first name middle initial last name Current Address (include mailing if different) Previous Address and Dates of Residence Aliases (include previous married names, maiden name) Have you been convicted of any crimes in the past 10 If so, what?
CONSENT TO RELEASE INFORMATION RELEASE FROM LIABILITY TO WHOM IT CONCERN: I am an applicant for a position with the (Port District of South Whidbey Island). The Port needs to thoroughly investigate my employment background and personal history to evaluate my qualifications to hold the position for which I have applied. I have authorized PDSWI to gather all available information regarding my employment background and personal history and other information which may be of a confidential or privileged nature. I, the undersigned, authorize you to furnish PDSWI any and all information that you have concerning me, including without limitation my work record, my background and reputation, my criminal history; including any arrest records and any information contained in investigative files, and any other personal records, including medical, psychological, military service or financial matters. Information of a confidential or privileged nature may be included in the materials you provide to PDSWI. I further specifically consent to the Washington Department of Revenue’s release of any tax returns, as defined by RCW, filed by, on behalf of; or with respect to me, and any tax information, as defined by RCW, that pertains to me. I request your cooperation in supplying this information to PDSWI in response to a request from that office. I hereby agree to release you and those who supplied you with the above information, your company or organization, and the Port District of South Whidbey Island, its Directors, employees and or agents, from any liability for any damage with may result from furnishing the requested information. Applicant’s Signature date Driver’s License # (please include !) Applicant’s printed first name middle initial last name Current Address (include mailing if different) Previous Address and Dates of Residence Aliases (include previous married names, maiden name) Have you been convicted of any crimes in the past 10 If so, what?
Consent-Form-EDITED.docx