Town of Brookfield
Fire Department
645 Janacek Road
Brookfield, WI 53045
(262) 796-3792
Fax: (262) 796-0410

AUTHORIZATION FOR RELEASE OF INFORMATION
(FOR OFFICIAL USE ONLY; NOT TO BE RELEASE TO UNAUTHORIZED PERSONS)
"I hereby empower an employee of the Town of Brookfield Fire Department or other authorized representative bearing this release to, within one year of its date, to obtain information and records pertaining to me from any or all of the following sources:"
  1. Municipal, State, Federal law enforcement agencies
  2. Selective Service System
  3. Any banking institution
  4. Any place of business (for the purpose of obtaining credit or employment data)
  5. Credit rating bureaus or institutions maintain individual credit rating files
  6. Any previous employer
  7. Present employer
  8. Any school, college, university or educational institution
  9. Any office, clinic, sanatorium or hospital where illnesses, injuries, and/or deterioration (physical and/or mental in nature0 are diagnosed and treated (post-conditional job offer)
"I hereby release any Municipal, State, Federal law enforcement agency, individual or institution, including its officers, employees or related personnel, both individually and collectively, from and all liability for damage of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information or any attempt to comply with it."

Exceptions to this blanket authorization:
  1. __________________________________________________________________________

  2. __________________________________________________________________________

  3. __________________________________________________________________________
  • Print Full Name______________________________________________________________________

  • Signature Full Name__________________________________________________________________

  • Print Witness Full Name_______________________________________________________________

  • Signature Witness Full Name___________________________________________________________
Date: _______/_______/_______

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