TO WHOM IT MAY CONCERN:
I, ____________________________, am seeking employment or volunteer assignment with the
Lockwood School District. I acknowledge that a complete investigation into my background is necessary
to protect the safety and welfare of the children in the Lockwood School District. I hereby expressly and
voluntarily give the Lockwood School District the right to make a thorough investigation of my past
employment, education, and activities. I specifically authorize the release of any and all information of a
confidential or privileged nature, including confidential criminal justice information as defined in Section
44-5-103(3), MCA, to the staff of the Sample School District and its agents. I understand that the
Lockwood School District reserves the right to use any lawful method of investigation that, in its sole
discretion, it deems reasonable and necessary.
I hereby release the Lockwood School District and any organization, company, institution, or person
furnishing information to the District and its agents as expressly authorized above, from any liability for
damage which may result from any dissemination of the information requested, subject to the provisions of
Title 44, Chapter 5, Part 3, MCA.
This document is effective until revoked in writing by me.
SIGNATURE _______________________________________ DATE ___________
Print Full Name: ___________________________________
Print Full Address: __________________________________
______________________________________________________
City State Zip
Birth Date: ________________ Social Security Number: ________________
STATE OF MONTANA )
: ss.
County of )
On this _____ day of ________________________, 200_, before me, a notary public of the State of
Montana, personally appeared _________________________________, known to me to be the person
named in the foregoing Release, and acknowledged to me that _________________ executed the same as ___________________ free act and deed, for the uses and purposes therein mentioned.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal the day and year
in this certificate first above written.
________________________________
Notary Public, State of Montana County of _______________________
My commission expires ____________