Cjstc Form 58 – Fill Out and Use This PDF

To: Concerned Person or Authorized	APPLICANT’S NAME:
Representative of Any Organization,
Institution or Repository of Records	DATE OF BIRTH:
	SOCIAL SECURITY NUMBER (Optional):
EMPLOYING AGENCY REQUESTING BACKGROUND INFORMATION:				TCC Criminal Justice Selection Center

I hereby authorize any employee or authorized representative bearing this release, or copy thereof, to obtain any information in your files pertaining to my employment records including, but not limited to, achievement, attendance, personal history, disciplinary records, medical records, credit records, and criminal history records. I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for the official use of the requesting agency. Consent is granted for the agency to furnish such information, as is described above, to third parties in the course of fulfilling its official responsibilities. I hereby release you, as the custodian of such records, and employer, educational institution, physician, hospital or other repository of medical records, credit bureau or consumer reporting agency, including its officers, employees, and related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. A photocopy of this form will be as effective as the original.

I hereby authorize the National Records Center, St. Louis, Missouri, or other custodian of my military record to release information or photocopies from my military personnel and related medical records, including a photocopy of my DD 214, Report of Separation, to:

TCC Criminal Justice Selection Center, 75 College Drive, Suite 203, Havana, FL 32333

Section 768.095, F.S., titled Employer Immunity from Liability; disclosure of information regarding former or current employees states: An employer who discloses information about a former or current employee to a prospective employer of the former or current employee upon request of the prospective employer or of the former or current employee, is immune from civil liability for such disclosure of its consequences, unless it is shown by clear and convincing evidence that the information disclosed by the former or current employer was knowingly false or violated any civil right of the former or current employee protected under chapter 760, Florida Statutes. Pursuant to Sections 943.134(2)(a) and (4), F.S., Chapter 2001-94, Laws of Florida, disclosure of information is required unless contrary to state or federal law. Civil penalties may be available for refusal to disclose non-privileged legally obtainable information.

Applicant’s Signature			Date
Applicant’s Address
		AFFIDAVIT
STATE OF		COUNTY OF

Before me personally appeared ________________________________________ who says that he/she executed the above instrument of his

or her own free will and accord, with full knowledge of the purpose therefore.

Sworn and subscribed in my presence this ________________ day of ___________________________, 20____________. My Commission

expires on ________________________, 20___________. Personally Known							- or -
Produced Identification			Notary Public:
Type of identification produced:

Effective: 8/9/2001 Pursuant to	Original – Employing Agency	Revised 8/3/2006
Sections 943.134(2)(a) and (4), F.S.