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| CONSENT TO BACKGROUND CHECK AND TAX RECORD DISCLOSURE AND RELEASE |
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By checking the box below, I further authorize the Office of the
Governor to conduct any and all criminal background checks or investigations
concerning me that the Governor's Office deems appropriate. I further authorize
the Office of the Governor, in connection with any criminal background checks or
investigations, to use any and all information included in my application for
appointment for such purposes, and to consult with and seek information from
appropriate law enforcement agencies or entities, including but not limited to
the Arkansas State Police and the Arkansas Crime Information Center.
By checking the box below, I further voluntarily consent to and request that the
Director of the Arkansas Department of Finance and Administration disclose to the
Office of the Governor, pursuant to Arkansas Code Annotated Section 26-18-303(b)(5),
any information which the Director or the Department may have concerning me as a
taxpayer, and that the Director likewise provide to the Office of the Governor
information concerning my Arkansas driver's license.
By checking the box below, I hereby request and authorize any person, agency or
entity, private or public, including all courts, law enforcement agencies, military
services, and tax offices, having information, documents, or records about me, to
release and provide the same to Governor Asa Hutchinson, his Legal Counsel, his Director
of Appointments to Boards and Commissions, or to the Arkansas State Police, for
his/their use in performing a background check on my ability and fitness for the
sensitive appointment I seek.
By checking the box below, I do hereby release and discharge the Office of the
Governor, the Governor, the Arkansas State Police, the Departments of Finance and
Administration, and any other agency or person utilized by the Governor in
performing any background check of me, from any and all liability of every kind
arising from furnishing documents, records, or other information for use by the
Governor in this matter.
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