Willamette University

Campus Safety

Release and Applicant Information Form

Sonic e-Learning Inc.

185 Bartley Drive, Suite #1
Toronto, ON M4A 1E6

(877) 867-6642 voice

(866) 462-6316 fax

Requestor Information:

Rich Dennis

Willamette University

(503) 370-6907 voice

(503) 375-5384 fax

Note: Field Names in Red are Required.

Name:
E-mail:
Home Phone:
Current Address:
City:
State:
Zip:
Previous Address:
Previouse City:
State:
Zip:
Previous Address:
Previous City:
Previous State:
Previous Zip:
I will be driving: (check all that apply)
a University van
a private vehicle
Applicant’s Name: (by submitting this form electronically, I also submit my signature electronically)

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.