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Campus Safety

Willamette University
900 State Street
Salem, Oregon 97301

503-370-6911 voice
503-375-5384 fax

Release and Applicant Information Form
Sonic e-Learning Inc.
185 Bartley Drive, Suite #1
Toronto, ON M4A 1E6
Phone: (877) 867-6642 Fax: (866) 462-6316

Requestor Information:

Company Name: Willamette University

Contact Person: Rich Dennis

Contact Phone: 503-370-6907

Contact Fax: 503-375-5384

Applicant/Subject Information:
Required fields*

Name
E-mail Address*
Home Phone*
Current Address*
City*
ST*
Zip*
Previous Address
City
ST
Zip
Previous Address
City
ST
Zip
Date of Birth* (mm/dd/yyyy)
Drivers License Number*
State*

I will be driving
a University van
a private vehicle (check all that apply)

In connection with any application made by me, I understand that investigative background inquiries may be made on me concerning matters of motor vehicle information. I understand that you may be requesting information from various Federal, State, and other agencies which maintain records concerning past activities relating to my driving records.

I authorize, without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from any liability and/or responsibility for doing so. I hereby consent to any potential employer obtaining such information from Sonic e-Learning Inc. and/or any of their agents. This authorization and consent shall be valid in an original, fax or copy form. I recognize that these inquiries may be made randomly in the future and no further authorization is required by me.

Applicant's Name*

(by submitting this form electronically, I also submit my signature electronically)