GENERAL CONSENT FORM

I, ______________________________, hereby give my consent for the release of any and all information, or copies of any information, evaluations by employers, or pertinent facts pertaining to myself, to the Central Blair Recreation and Park Commission for the sole purpose of completing a full background investigation for possible employment.

I understand that information will be disclosed only for the purpose noted above, and that the information released will be limited to the following areas or items.

A. Any and all criminal justice agencies.

B. Any and all past and present employment.

C. Any and all personal or professional references.

D. Any and all educational records or background.

E. Any and all motor vehicle operations records.

F. Any military service records.

I understand that I have no obligation whatsoever to disclose any information from my records, and I understand that I may revoke this consent at any time by notifying the Central Blair Recreation and Park Commission, in writing, and/or specifying a date, time or condition upon which my consent will expire without revocation, which I choose (NOT) to do. I have had this form read and explained to me and I understand its contents. I agree this form may be reproduced for additional copies.

/s/___________________________ /s/________________________________

Date signed Applicant

/s/ __________________________

Witness

This form is in compliance with the Privacy Act as established in 1974, and the above consent shall automatically expire:

Upon completion of background investigation

Social Security # ______________________________

Driver’s License # ______________________________

Date of Birth ______________________________