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AUTHORIZATION TO RELEASE INFORMATION
This is to certify that I, ________________________________, do hereby authorize the release of any and all information to the City of Manassas Park Fire & Rescue Department and that they may request, from whom ever they may deem it necessary to make such a request, from any of my records or files. Such information will include but not limited to; hospital records, medical records, military records, police records, arrest records, court records, police reports including juvenile records, credit reports, background investigative material and reports, employment records, attendance records, traffic records, confidential records, educational reports and transcripts, etc. I also release all persons from any liability which could result from furnishing said information to the City of Manassas Park Fire & Rescue Department.
Further, I authorize the City of Manassas Park Fire & Rescue Department to copy or otherwise reproduce this original document, and to let such copied or otherwise reproduced copy act as the original instrument.
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Date Print Name
________________________
Signature
Given under my hand this ______ day of ___________, in _________________. My commission expires, _________________________.
______________________________, Notary Public
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