In connection with my application for membership with the Merton Fire Department, I hereby authorize said department and any authorized agent acting on its behalf to conduct an investigative report on my background. I therefore authorize, request, and require any previous employers, educational institutions, organizations, companies, or persons so contact to furnish he above named department or it's agents any information they have concerning my work history and achievements, credit worthiness, general reputation, character, personal characteristics and mode of living. As an inducement to provide this information, I hereby release and forever discharge each and every such employer, educational institutions, organization, company or person from any and all claims of liability, in law or in equity, that may arise out of furnishing such information to the above named department or any authorized agent of the department. I further understand and agree that any false o misleading information given on my application during my membership interview is considered grounds for dismissal and may result in my termination at the department option. I further give said department lasting permission to reinvestigate my background at any time in the future during my term of membership with them for any reason they so desire.

My signature below indicates my understanding and acceptances of all the above terms and stipulations.