Fill and Sign the Applicant Authorization Reference Form

APPLICANT AUTHORIZATION FOR REFERENCE CHECKS I hereby authorize my past employers to release information to       [Insert Employer’s Name] regarding my employment. This release of information covers my employment record in general, including information on the following questions: 1. Dates of employment 2. Position(s) held 3. The quality and quantity of my work 4. My attendance habits (excluding workers' compensation, pregnancy, disability FMLA and other protected absences) 5. My relationship with co-workers, supervisors and managers 6. My attitude toward work (cooperative? positive? etc.) 7. Reason for leaving and eligibility for rehire (would the employer rehire if they had to do it all over again?) 8. Strong and weak points 9. Willingness to comply with policies and standards 10. Whether I have had outbursts of temper, threatened, provoked fights with or assaulted others, engaging in hostile or violent behavior 11. Other relevant information regarding my performance, skills, ability, suitability for employment sought, etc. I agree that all former employers who provide such information are indemnified and released from liability arising from such disclosures. I also understand that if I do not sign this Authorization, my application will be rejected.       Print Name Signature Date