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3. 
5. Authorization for release of information in connection with employment application and other "employment" purposes including reference checks and verification
7. I authorize the Town of Middleburg Police Department, or any representative of the department who can present credentials for the same, to conduct an investigation related to my work and personal history. To that end, I authorize any employer, friend, foe, school, corporation, government or government sub-divisions/agency, licensing agencies, or any other entity or person to release and or allow access to information that the investigating officer deems relevant to my possible employment or internship with the Middleburg Police Department, Specific authorization is granted for any disciplinary files, internal investigation files, browsing histories on public or company computers, and phone records for public or company phones. This authorization includes, but not limited to, authorization for the Town of Middleburg to check and verify any information contained in my employment application.
9. I further release all parties referred to herein and the Town of Middleburg and/or employees from all liability and responsibility arising from the release of information concerning me.
11. I hereby authorize all of the aforesaid enumerated parties to furnish the Town of Middleburg Police Department any and all information concerning me that they, the investigating representative, deem relevant to my application.
13. First Name
14. Last Name
16. Driver's License Number
17. Date of birth
    Date of birth
19. Please list all other names that your information may be listed under:
23. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
25. Electronic Signature
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field