{date95}
I, {name} have made application to the Mississippi Department of Public Safety and desire them to be informed of my past records and character
wheather it be financial, academic, military, medical employment, judicial, or personal references. I, the undersigned, being under no disability whatsoever, herby authorize the release of all such information, privileged or otherwise, the Department of Public Safety and its representatives, and release all contributing parties of such information from any charges or liabilities whatsoever and through the furnishing of said information.