AUTHORIZATION FOR RELEASE OF INFORMATION

I authorize the Chapman Corporation to perform a criminal history record check

in connection with my application for employment or my employment with

Roanoke Rapids Graded School District pursuant to N.C.G.S. 114-19.2 and

115C-332a.

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Last Name First Name Middle Name Maiden Name

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Social Security Number Date of Birth Sex Race

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Current Address (City, State, and Zip Code)

Additional Addresses in the last 7 years. List most current first.

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I understand that the Chapman Corporation and its employees, as well as the

Roanoke Rapids Graded School District, shall not be held legally accountable in

any way for providing this information to the above named school system, and

hereby release said agency and persons from any and all liability which may be

incurred as a result of furnishing such information. I further understand that the

Roanoke Rapids Graded School District cannot release the results of this

criminal history record check to me.

Applicant’s/Employee’s Signature

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Date

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