Custodian Public

Release of Information to Another District / ISD / ESA / School if desiring to work in more than one district, school, etc. or if you have been fingerprinted for another district, school, etc.

I, Santana Buckmaster (Print Name) authorize Hastings (New District, School etc.) to obtain from Dewitt (District, School, etc. that currently holds your prints) all information and reports about the criminal record check conducted by releasing District, School, etc. I understand this information is required by Public Act 9, amended by Public Act 68. I fully release both Districts, Schools, etc. to the maximum extent permitted by law from any liability whatsoever in connection with either the release or use of the report required by Public Act 99, amended by Public Act 68.

Signature Date

Santana Buckmaster Custodian

Printed Name Position with GRBS

8835 09/21/87

Last four (4) digits of SSN Date of Birth

NOTE: Please provide the date of the last day worked for GRBS: Presently working