Forms • Burnsville • CivicEngage

Authorization for Release of Information

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Last Name*

First Name*

Middle Name

Maiden Name (if applicable)

Street Address*

City*

State*

Zip Code*

Date of Birth (mm/dd/yyyy)*

Ethnicity

Sex*

Male

Female

Driver's License #*

State of Issue*

Position Applied For*

List Prior Places of Residence (COMPLETE ADDRESS AND DATES) for past ten years*

I have applied for a volunteer position with the City of Burnsville. As part of the evaluation of my suitability for volunteering in this position, a background investigation is to be conducted. I authorize the Burnsville Police Department to conduct the background check in the following areas:

Criminal History Check
Local Police Record Check
Warrant Checks
Driver’s License Check
Historical Address Check

By checking "Yes," I authorize the Burnsville Police Department to disclose this information to the Human Resources Department for the purpose of volunteering with this agency.*

Yes

* indicates required fields.

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