Personal Reference Authorization Release Form

Applicant Information

Full Name Date of Birth Address Phone Number Email Address

Reference Information

Reference Name Relationship Reference Contact Information

Authorization & Release

I hereby authorize the above-listed reference to provide information regarding my character, employment or academic performance, and/or any other relevant information as requested in connection with my application. I release all such references from any liability for providing information in good faith, and I understand that this authorization and release will be used for the purpose of evaluating my application.