Employee Record Release

EMPLOYEE RECORD RELEASE

Employee Name:   Employee ID:

Employer Name:   HR Contact:

Recipient (Authorized to Receive Records):

Scope of Records to be Released

The undersigned authorizes the Employer to disclose the following records to the Recipient identified above. Check all applicable categories.

Personnel file (including application, offer letter)

Performance evaluations and disciplinary records

Attendance, timekeeping, and leave records

Payroll, wage, and salary records

Benefits enrollment and claims information

Drug/alcohol testing and results

Background check reports and investigatory records

Termination and separation documentation

Promotion and compensation history

Purpose and Timeframe

Records covering the period from to

Release type:    One-time release    Ongoing release until revoked    Release until

Personal Information

Position Information

Employment History (Most Recent)

Education

References

Legal Disclosures

At-Will Employment Statement: Nothing in this Employee Record Release alters the at-will employment status of the employee or creates any contract of employment for a definite term. The employee or Employer may terminate the employment relationship at any time, with or without cause or notice, unless otherwise expressly provided in a separate written agreement signed by both parties.

Equal Opportunity Statement: Employer is an equal opportunity employer. Release and disclosure of records pursuant to this authorization shall be conducted without regard to race, color, religion, sex, national origin, age, disability, or other protected status as defined by applicable law.

Authorization and Certification

By signing below, I certify that I am the individual named above (or am authorized to act on behalf of the individual) and I hereby authorize the Employer to release the records specified in this form to the Recipient for the purpose(s) stated. I understand that the information released may include both public and non-public personnel information and that such disclosure is limited to the categories checked above.

I release and hold harmless the Employer, its agents, and employees from any liability for disclosure of information pursuant to this authorization to the extent permitted by law. I further understand that the Recipient may redisclose information and that such redisclosure may no longer be protected by Employer policies. I acknowledge that I may revoke this authorization at any time by providing written notice to the Employer; however, revocation will not apply to disclosures already made in reliance on this authorization.

I authorize Employer to contact prior employers, references, or third parties as necessary to verify employment history and records included in this release. I understand that Employer may require reasonable fees to reproduce records, and that payment of such fees may be required prior to release.

Acknowledgment:
I understand and authorize the release described herein.

Recipient and Employer Contact Information

Applicant Certification

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information may subject me to disciplinary action up to and including termination of employment or other remedies permitted by law.

Sign Now