Fingerprints Release – PRG Michigan App

Fingerprints Release Form

Please complete this section if your fingerprints are maintained at a school, ISD, or agency.

Email Address(Required)

Use the same email on all forms.

Cell Phone(Required)

Use the same cell phone on all forms.

School Information

School Name(Required)

Where Your Fingerprints Were Printed - ISD, School or Agency

School Phone(Required)

School Fax

In connection with my application for employment through Choice Schools Associates, and pursuant to Section 1230b of the Revised Michigan School Code of 1976, Act No. 451 of the Public Acts of 1976. I, the undersigned, hereby authorize the above states ISD, School, or Agency to disclose to the academy below all the information and reports about the criminal record check maintained by said ISD, School, or Agency and to make available to the academy listed below copies of all documents related to said criminal record check.

I further release the above ISD, School, or Agency from any liability from providing the information described above and waive any written notice required under section 6 of the Bullard-Plawecki employee right to know act, Act No. 397 of the Public Acts of 1978, being second 234.506 of the Michigan Compiled Laws.

It is my understanding that the academy(s) listed below will hold any information obtained in the course of this investigation will be held strictly confidential.

Forward this fingerprint release and fingerprints to all selected below:
Along with this form please also send the original live-scan form which will include TCN#

TCN #

Date of Birth(Required)

Signature

Signature(Required)

Use the box below and sign your name.

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Date of Signing(Required)