AFFIDAVIT FOR RELEASE OF INFORMATION

I hereby authorize the Alabama Law Enforcement Agency to conduct a criminal history background check and to release my criminal history information to the State Superintendent of Education. I do hereby for myself, my heirs, executors, and administrators release and forever discharge the Alabama Law Enforcement Agency and its officers and agents from any and all claims, actions, or causes of action which may arise as a consequence of the release of the criminal history information as authorized herein.

If I am an applicant for certification or licensure, or if I am a certified or licensed applicant for employment in a public school, or an applicant for employment at a nonpublic school, or an applicant for a teacher education program, then I understand that the State Superintendent of Education shall provide a suitability determination based on the State Bureau of Investigation and Federal Bureau of Investigation criminal history background information reports.

If I am applying for employment in a non-certified or non-licensed position in a public school then I understand that my potential employer will be notified of my confirmed convictions and pending charges.

I understand that I may be denied employment, unsupervised access to children, the opportunity to serve, or certification or licensure based upon the information contained in the criminal history background information check.

I understand that a refusal to consent to a criminal history background check will result in me not being hired or, if applicable, me not being certified or licensed.

I am aware that I have the right to obtain a copy of the background check report and to challenge its accuracy and completeness. The procedures for obtaining a change, correction, or updating of an FBI identification record are set forth in Title 28, CFR, � 16.34. I also have a right to obtain a prompt determination as to the validity of such challenge before a decision to retain or hire is made by an employer. Officials making such a determination should not make a decision regarding my license or employment based upon information in the record until I have been afforded a reasonable time to correct or complete the record, or have declined to do so.

I understand that I am entitled to due process in accordance with applicable statutes prior to any possible adverse action taken as a result of information reported from a criminal history background check.

Payment of fingerprint fees and submission of fingerprints shall be deemed further positive affirmation of my intent to have a fingerprint based criminal history background check performed as authorized above.

(Print terms)