Employment History Release Authorization

I hereby authorize the release of my employment records and related information by my former and present employers to the organization listed below for the purpose of employment verification and reference checking.

Applicant Information

Full Name:

Address:

Phone: Email:

Employer/Organization Requesting Information

Name:

Contact Person: Phone:

Authorization & Acknowledgment

I understand that the information released is for employment purposes only and will be kept confidential, except as required by law. I release all parties from any liability that may result from providing or using such information.

Applicant Signature:

Date: