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INFORMATION / DISCLOSURE RELEASE I, the undersigned applicant/employee, hereby expressly authorize the Watauga County Board of Education, its agents and employees, to make any investigation of my personal or employment history, expressly including, but not limited to federal and/or state criminal, law enforcement or traffic records. I further authorize any former employer, person, firm, corporation, administrative body or governmental agency to give to the Watauga County Board of Education, its agents or employees, any information they may have regarding me. In consideration of the review of my employment application by the Watauga County Board of Education, its agents or employees, I hereby release the Watauga County Board of Education, its agents or employees and any and all providers of information to whom this release is sent, from any liability as a result of furnishing or receiving this information. Employee Signature _______________________________________________

Date: _________________________

Please Type or Print All Information: _________________________ Last Name

_______________________ First Name

______________________ _________________ Social Security # Date of Birth

____ Sex

______________________ Middle Name _________ Race

______________________ Maiden Name

_____ Handicapped

_______ Veteran

NOTE: Indicate below, where you have lived for the past ten years. (Use back of page if needed). Current Address: Yrs.____Mos.____

_______________________________________________________________________________ Street Address _______________________________________________________________________________ City State Zip Code

Previous Address: Yrs.____Mos.____

_______________________________________________________________________________ Street Address _______________________________________________________________________________ City State Zip Code

Previous Address: Yrs.____Mos.____

_______________________________________________________________________________ Street Address _______________________________________________________________________________ City State Zip Code

Previous Address: Yrs.____Mos.____

_______________________________________________________________________________ Street Address _______________________________________________________________________________ City State Zip Code

DRIVERS LICENSE #________________________________STATE________________ISSUE DATE:______________ FOR PERSONNEL USE ONLY REPORTS REQUESTED ______ Statewide Criminal Records States to Search: ______________________________ ____________________________________________ ______ Countywide Criminal Records for State of: ________

Counties to Search:________________________ ________________________________________ ______ DMV Report Requested by:__________________________________ Date:_________________

Information Disclosure Release  

Please Print and bring to the MA office

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