Concord Community School District FINGERPRINT

Concord Community School District FINGERPRINT REQUEST FORM If you have been Livescan fingerprinted since January 1, 2006 and the record is maintained at another school or ISD, please complete this form. There can be no separation of employment. If there is a separation of employment you must be fingerprinted again per state law.

PERSONAL INFORMATION Your Name:

_________________________________________

Your Address: _________________________________________ (Street)

______________ ______________ ___________ (City)

(State)

(Zip)

SSN:____-_____-______

REQUESTING FROM ISD, SCHOOL NAME:_________________________________________ ADDRESS:

_________________________________________ (Street)

______________ ______________ ___________ (City)

(State)

(Zip)

This signed Release authorizes fingerprint information to be forwarded to: Concord Community Schools Attn: Laurie Sinden PO BOX 338 405 S Main St Concord MI 49237 EMAIL: [email protected] Fax: (517)524-8613 – call first before faxing

Please fill in the following: I, _____________________, authorize Concord Community Schools to obtain from the above stated school district (where prints are maintained), all information and reports about the criminal record check maintained by said school district pursuant to Public Act 99, amended by Public Act 68, I understand this information is required by P. A.99, amended by P.A. 68. I fully release the above stated school district (where prints are maintained) and Concord Community Schools to the maximum extent permitted by law from any liability whatsoever in connection with either release or use of the report required by P.A. 99, amended by P.A. 68. ________________________________ Signature

______________________ Date