Authorization for Release of Information

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Authorization for Release of Information

Name of applicant: _________________

Social security number: ____________

Date of application: _______________

Position applied for: ______________

TO:

You are authorized to release information concerning my employment with you, or if you are a personal/academic reference, release information concerning my employment and education, including subject evaluations to ______________________.

You are further released from liability in connection with your response to this inquiry.

A photocopy of this authorization will be as effective as an original.

___________________________________________

Requester

Please send it to the following person.

________________________

Attention: _________________

____________________________

____________________________

Telephone: _________________

If there are any charges connected with this transaction, please charge:

My Credit Card Number: Expiration Date:

Exact Name on Card:

If you require a check, please contact me at the above address, by fax, email, or phone, and I will send one forthwith.

I hereby authorize the charges for this service.

____________________ Date:

Requester

Please email, fax, or phone me to confirm you have completed this transaction. Many thanks in advance for your assistance,

____________________ Date:

Requester