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FPM Chapter 732 AUG-31-1994 14:42 FROM r UNIT . Toa - @ WIMFO P.i4 r tr Standard Forrn 86 Form approved: Revised December 1990 ' O.M.8, No, 32064007 . NSN 7580-00-634-4096 U.S.Office of Personnel Management 88-110 UNITED STATES OF AMERICA AUTHORIZATION FOR RELEASE OF INFORMATION Carefully read this authorization to release information about you, then sign and date it in ink. I Authorize any investigator, special agent, or other duly accredited representative of the U.S. Office of Personnel Management, the Federal Bureau of Investigation, the Department of Defense, and any authorized Federal agency, to obtain amy information relating to my activities from schools, residential management agents, employers, criminal justice agencies, retail business establishments, or other sources of information. This information may include, but is not hmited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, and criminal history record information. 1 Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of information, a separate specific release will or may be needed, and I may be contacted for such 2 release at a later date. I Further Authorize the U.S. Off ce of Personnel Management, the Federal Bureau of Investigation, the Department of Defense, and any other authorized agency, to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for, assignment to, or retention in, a sensitive position, in accordance with 5 U.S.C, 9101. 1 Authorize custodians of records and sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary. I Understand that the information released by records custodians and sources of information is for official use by the Federal Government only for the purposes provided in this Standard Form 86, and may be redisclosed by the Government only as authorized by law. Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for two (2) years from the date signed. Other Names Used Abmer J. Mikva ‘Aug. 22, 1994 oclal Securty Humber 394, | -|16 |. PF4e , Home Telephone Number (Inctude Area Code) b6 AUG 31 °94 13:22 . e6@2 32@4 1397353 PAGE. 14