Employee File Transfer Release

EMPLOYEE FILE TRANSFER RELEASE

Employee Identification

Position Information

Hire Date:    |    Last Day Worked (if applicable):

Transfer Details

Recipient Name:    Organization:

Effective Transfer Date:    Date Range of Records to Transfer: From to

Secure electronic transfer (encrypted file transfer)
Physical copy / courier delivery
Encrypted email
Third-party records vendor

Personnel file (employment history, offer letters)
Payroll and compensation records
Benefits enrollment and related documents
Performance evaluations and appraisals
Disciplinary and corrective action records
I-9 and employment eligibility documents
Medical or health-related records (requires specific consent)
Training, certifications, and licenses
Other:

Employment History

Title:    Dates Employed:

Title:    Dates Employed:

Education

Graduation Date:

References

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Legal Disclosures, Authorizations and Consent

At-Will Employment Statement: Employment with the employer is at-will unless a written agreement signed by an authorized representative expressly states otherwise. Nothing in this Release is intended to modify or alter the at-will employment relationship.

Equal Opportunity Statement: The employer prohibits discrimination and provides equal employment opportunity in accordance with applicable law. This Release is not a waiver of rights guaranteed by law.

Authorization to Release Records: I, Employee Name: , hereby authorize the employer identified above to disclose and transfer the personnel records and other items checked in this document to the recipient named herein for the stated purpose. This authorization includes the release of non-confidential employment records and, where specifically checked, medical or health-related records to the extent permitted by law and subject to any additional consents required by statute.

Background Checks and Prior Employers: I authorize the employer and the recipient to contact prior employers and listed references for verification of employment history and references. I also authorize the employer to provide to the recipient copies of background check results and related investigative reports if such materials are part of my personnel record and if state or federal law permits disclosure.

Revocation: This authorization may be revoked by me in writing at any time, except to the extent that action has already been taken in reliance on this Release. Revocation does not affect disclosures previously made by the employer in good faith under this authorization.

Confidentiality and Use Limitation: The recipient is directed to maintain confidentiality of transferred records and to use such information solely for the purpose stated above. Any further disclosure by the recipient must be consistent with applicable law and this Release.

Indemnification and Release of Liability: I release and agree to hold harmless the employer and its agents from any liability arising from the release of records in accordance with this Release and from any use of the records by the recipient, except where caused by the gross negligence or willful misconduct of the employer.

Governing Law: This Release will be governed by and construed in accordance with the laws of the state where the employer's principal place of business is located, without regard to conflicts of law principles.

Applicant Certification

I certify that all information provided in this form is true and complete to the best of my knowledge. I understand that knowingly providing false information or knowingly authorizing the release of falsified documentation may result in disciplinary action up to and including termination.

I authorize release of the records as specified above and acknowledge the statements and disclosures contained in this Release.

Additional Instructions / Notes

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