AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize Natchez Trace Management Association and their agents to receive any
CRIMINAL HISTORY record information pertaining to me which may be in the files of any state
or local criminal justice agency.  I release all parties from liability for damages for issuing such
information in good faith.
FULL NAME (print): ____________________________________________________________

SSN: ________-________-________

ADDRESS: ________________________________________________ APT# ______________

CITY:         _______________________________STATE:______________ZIP______________



THE FOLLOWING INFORMATION IS REQUIRED TO INSURE AN ACCURATE
MATCH AND IS NOT USED FOR ANY OTHER PURPOSE:

SEX:__________                         RACE:__________                    DATE OF BIRTH:___________
SIGNATURE: ___________________________________________
DATE: ________________