Employment

Authorization for Release of Information

Vicky Randolph Vicky Randolph
How To Use

This review list is provided to inform you about this document in question and assist you in its preparation.  This general authorization for Release of Information can be more useful than some of the more specific ones offered elsewhere. This multiple part document covers the necessary elements in getting a reference, release of information, charges due thereto, and confirmation back to you as the requester.

  1. Make multiple copies. Mark your calendar to send a second notice if you have not heard back in two weeks.  Stay on top of this.

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