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: _________________________

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_________________________ _______________________ ______________________ ______________________ Last Name First Name Middle Name Maiden Name ______________________ _________________ ____ _________ _____ _______ Social Security # Date of Birth Sex Race 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:_________________