For (circle one):           Employment                            Volunteer

Name:_________________________________________________________________________

Address:________________________________________________________________________

City/State/Zip:___________________________________________________________________

Home Phone:______________________________    

Cell Phone:____________________________

Driver’s License #:__________________________________

Exp. Date:_______________________________

Date of Birth:________________________________________   SSN:_________________________________

State of Birth:_________________________________________________________________

AUTHORIZATION TO RELEASE INFORMATION

I, _________________________________, hereby authorize any person, agency, partnership or corporation having any information concerning my Education Record, Employment Record, Military Record, or Police or Department of Child Services Records from any and all police agencies, to release such information to the Roanoke Public Library. This information is to be used for employment with the Roanoke Public Library and will not be available for public inspection per the Library’s Public Access Policy.

I hereby release such persons, agency, partnership or corporation from any liability, which may be incurred in releasing this information to the Roanoke Public Library including under State and Federal law.

__________________________________________________                        ___________________

Signature                                                                                                                                  Date

Note: Checks will be completed every 5 years while employed at the Roanoke Public Library.