OS - AUTHORIZATION TO RELEASE INFORMATION - HERLIHY, JOHN F.

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 0005549288
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 1
• Document Creation Date: June 24, 2015
• Document Release Date: September 8, 2011
• Case Number: F-2010-00553
• Publication Date: January 15, 1991

(b)(3)
(b)(6)
AUTHORIZATION TO RELEASE INFORMATION
To Whom It May Concern:
I hereby authorize any Investigator or duly accredited representative of the United States
Government bearing this release, or a copy thereof, within one year of its date, to obtain any
information from schools, residential management agents, employers, criminal justice agencies,
or individuals, relating to my activities. This information may include, but is not limited to, ac-
ademic achievement, performance, attendance, personal history, disciplinary, residential,
credit, medical, birth and other vital records, criminal, civil and domestic court records, and
conviction and arrest records. I hereby authorize and request your release of such information
upon request of the bearer. I understand that the information released is for official use only by
authorized agencies of the U.S. Government as necessary in the fulfillment of official
responsibilities.
I hereby release any individual, including record custodians, from any and all liability for
damages of whatever kind or nature which may at any time result to me on account of compli-
ance,. or any attempts to comply, with this authorization. Should there be any question as to the
validity of this release, you may contact me as indicated below.
Signature (Full Name):
Full Name (Printed):
Other Names Used:
Date:
Current Address:
Telephone Number:
Parent or Guardian (If Required):
Authority for Collecting Information
E. O. 10450 and E. O. 12356
APPROVED FOR
RELEASES DATE:
21-Jul-2011
Purposes and Uses
Information provided on this form will be furnished to individuals in order to obtain information regarding your activities in connection with an
investigation for security clearances or access. The information obtained may be Furnished to authorized agencies of the U.S. Government as
necessary in the fulfillment of official responsibilities.
F.Bects of Nondisclosures
Furnishing the requested information is voluntary, but failure to provide all or part of the information may result in a lack of further consider-
ationfor clearances or access.
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6-89M 3297 (USE PREYIOUS EDITIONS)