Office of the Governor
State of Maine

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
PERSONAL APPOINTMENTS

I,                                                                               , do hereby authorize a review of and full disclosure of all records or any part thereof concerning myself in the possession of the State Bureau of Identification by the Office of the Governor, whether said records are of a public, private, or confidential nature.  

I understand release of these records may be permitted pursuant to 16 M.R.S.A. § 611 et seq. regardless of this authorization.  

It is the intent of this authorization to provide access to said records for the specific purpose of undertaking a background investigation, which may provide pertinent data in determining my suitability for employment, appointment, or commissioning by the State of Maine.  I understand non-conviction data may be pertinent for that purpose.

I understand that any information obtained by the personal history background investigation, whether developed directly or indirectly, in whole or in part, upon this release authorization will be considered in determining my suitability for employment, appointment, or commissioning by the State of Maine.  

I acknowledge that this has been fully and clearly explained to me and fully understand that the refusal to grant authorization will not, of itself, constitute a basis for rejection of my application.

A photocopy or electronic version of this release will be valid as an original hereof.

SIGNATURE                                                                                       DATE                                  
STREET ADDRESS                                                                                                                        
DOB                                     SSN                                                PHONE                                        
WITNESS SIGNATURE                                                                                                                
WITNESS NAME                                                                                                                            
VALID UNTIL __                                                                                                                            

(207) 287-3531 (Voice)	             1 State House Station, Augusta, ME  04333	      (207) 287-1034 (Fax)