All applications will be reviewed by the Pardon Board. The governor may pardon only Louisiana convictions and cannot pardon a federal criminal offense or offense from another state.
Carefully read this authorization to release information about you, then complete, sign and date it in ink.
I authorize any duly accredited representative of the Louisiana Pardon and Parole Board or the Louisiana
Department of Corrections, to obtain any information relating to my activities from schools, residential
management agents, employers, criminal justice agencies, retail business establishments, courts, or
other sources of information. This information may include, but is not limited to, my academic,
residential, achievement, performance, attendance, disciplinary, employment history, criminal history,
arrest, conviction, including the pre-sentence investigation report, if any, medical,
psychiatric/psychological, health care, financial and credit information.
I understand that, for financial or lending institutions and certain other sources of information, a
separate specific release may be needed (pursuant to their request or as may be required by law), and I
may be contacted for such a release at a later date.
I further authorize the Louisiana Pardon and Parole Board or the Louisiana Department of Public Safety & Corrections,
or any other authorized state agency, to request criminal record information about me from criminal
justice agencies for the purpose of determining my suitability for a Pardon.
I authorize custodians of records and sources of information pertaining to me to release such
information upon request of any duly accredited representative of the Louisiana Pardon and Parole
Board or the Louisiana Department of Public Safety & Corrections or any state 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 State of Louisiana only for the purposes of processing my application for a pardon,
and may be re-disclosed by the State of Louisiana only as authorized by law.
I understand that pursuant to Act 52 of the 2016 Legislative session, should my application advance to
Stage 2 of the process, I agree to pay an assessment fee of $150.00 to the Louisiana Department of
Public Safety & Corrections for a clemency investigation to be conducted by the Division of Probation &
Copies of this authorization that show my signature are as valid as the original release signed by me.
This authorization is valid for one (1) year from the date signed.