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Deer Island Treatment Plant Tour: June 21st, 2013 @ 9:30 a.m. 11:30 a.m.

. (Young Professionals in Energy) Please fax form directly to: MWRA, Office of Emergency Preparedness (OEP) 617.371.1623 Commonwealth of Massachusetts Department of State Police
Criminal Information Section

*Please provide all required information; without it, your form will be rejected. The MWRA reserves the right to deny access to their property at their sole discretion.
AUTHORIZATION FOR RELEASE OF INFORMATION PLEASE COMPLETE THE FOLLOWING INFORMATION clearly in ink)
Name:
First Middle Last Initial

(Type or print

Previous Name or Alias (include Maiden


name):

Residential Address:
Number Street

City/Town

State

Zip Code

Mailing Address:

*Drivers
License # and Issuing State:

*Date of
Birth:

*Place of
Birth:

I, _____________________________________________, do hereby authorize a review of and a full disclosure of all records, or any part thereof, concerning myself, by and to an authorized agent of the Department of State Police, whether the said records are public, private or confidential in nature. The intent of this authorization is to give my consent for a Board of Probation (BOP) query and an Interstate Identification Index (III) query.

CIS Use Only BOP:_________

Officer:________________________________________________ III:______________ Other:_____________

ID#_________

I hereby swear, under the pains and penalties of perjury, that the information I have provided above is true, and to the best of my knowledge and belief. Signature Date

CIS Use Only BOP:_________

Officer:________________________________________________ III:______________ Other:_____________

ID#_________