Release of Records and Information

I,First Name Last Name hereby authorize and request that you release and request that you release and request that you release and furnish to a duly authorized agent, officer, or employee of the City of Belvidere, any and all records, documents or information you have in your possession or control pertaining to my; employment, credit card, education, medical history, military records, and/ or criminal history.

This release is executed for the official use by the City of Belvidere of these records or information. You are requested not to furnish such information to any other person or organization without written authorization from me. I hereby release any person or persons providing or receiving such information from any and all liability for damages of whatever kind resulting to me and heirs or assignments.

A photocopy of this authorization shall be valid as the original

Date

Applicants Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Signature

PLEASE NOTE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. Genetic information, as defined by GINA, includes an individual’s family medical history, the results of an individual’s or an family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.