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Release of Information Agreement

Release of Information Agreement


As part of its due diligence procedures, the City of Chamberlain requires that a background investigation and a check of references be conducted. The objectives of the investigation are to verify information provided during the application process, investigate references, and identify any factors that might be inconsistent with the City of Chamberlain’s employment requirements.

give the City of Chamberlain permission and authority to conduct a due diligence investigation and reference check into my past and current activities. I understand and consent to an investigation that may include, but is not limited to, information as to my personal character, general reputation, verification of previous employment and employment references, verification of education, credit history, motor vehicle driving record, social security wage information, criminal records, and other information contained in public records. In addition, I grant permission and authority to the City of Chamberlain to obtain past employment information in compliance with regulations of the U.S. Department of Transportation (DOT), including 49 CFR Part 40 and 49 CFR Part 382, regarding DOT drug and alcohol testing results from past employers.

I authorize and request Former Employers, Schools, Police Departments, States, Cities and Counties or any other Person to furnish the City of Chamberlain designees information concerning:

– Work Habits
– Character
– Criminal Records
– Social Security Information
– Reputation
– Driving Record
– Credit History
– Reason for Termination
– Medical History (Subject to the Americans with Disabilities Act of 1990 (ADA).
– Salary History
– Education History
– Transcripts
– Mental Health
– Military Records and Reports

*The Age Discrimination in Employment Act of 1967 (ADEA) prohibits discrimination of the basis of age with respect to individuals who are at least 40 years of age.

And all other relevant information requested by the City of Chamberlain, including confidential or privileged information, and provide copies of the same requested.

I hereby release all Persons, Companies, Corporations, Schools, of Individuals from all liability and responsibility that may result from providing the City of Chamberlain with such information as requested. All released information shall become property of the City of Chamberlain. All such information will not be further released to anyone other than the City of Chamberlain and agents of the same, and all efforts will be directed at maintaining the confidentiality of the information received.

I understand that if hired, my employment is for no definite period of time, consistent with state law, and may be terminated with or without cause and with or without notice, at any time, at the option of either the City of Chamberlain or myself. No employee representative, manager, official or supervisor of the City of Chamberlain, has any authority to enter into any agreement for employment for a specified period of time or make any agreement relative to employment that is contrary to the foregoing.

If I am not hired due to information contained in the background screen report, I will be notified in writing. I may request a copy of said report and it will be supplied to me in writing, along with a summary of my rights under the Fair Credit Reporting Act of 1970 as amended in 1996.