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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

Authorization for Release of Information
Review List

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.