HomeMy WebLinkAboutRelease & Waiver Austen ConnellaCityofSanLuisObispo, PoliceDepartment, 1042Walnut Street, SanLuisObispo, CA, 93401-2729, 805.781.7317, slocity.org
SAN LUIS OBISPO POLICE DEPARTMENT
1042 Walnut Street, San Luis Obispo, Ca., 93401
805) 781-7312 / CA0400600
RELEASE & WAIVER
As an applicant for a Commercial Cannabis business in the City of San Luis Obispo, I hereby authorize,
without reservation, The San Luis Obispo Police Department and its agents to conduct a full
investigation into my background and activities within (120) days of the date of my signature.
I understand that the scope of the investigation may include but is not limited to the following areas:
verification of social security number, credit reports, current and previous residences; employment
history, character references, civil and criminal history records from any criminal justice agency in any or
all federal, state, county jurisdictions; and any public record to include fire department and municipal
code violations and warnings.
I further authorize the complete release of any records or data pertaining to me which the individual,
company, firm, corporation, or public agency may have, to include information or data received from
other sources.
To the extent authorized by law, the San Luis Obispo Police Department and its designated agents and
representatives shall maintain all information received from this authorization in a confidential manner in
order to protect the applicant’s personal information, including, but not limited to, addresses, social
security numbers, and dates of birth.
Signature: ____________________________________ Date: ________________
State of California
County of__________________________________________}
On______________________before me,_________________________, Notary Public, personally
appeared___________________________________________________who proved to me on the basis of
satisfactory evidence, to be the person whose name is subscribed to the within instrument and
acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the
instrument the person, or the entity upon behalf of which person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and correct.
Witness my hand and official seal:
Notary Signature
A notary public or other officer completing this certificate
verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the
truthfulness, accuracy, or validity of that document.