Employee Release Authorization

EMPLOYEE RELEASE AUTHORIZATION

This Employee Release Authorization (the "Authorization") is made by the undersigned employee to permit the release and verification of employment-related information as necessary for employment, continued employment, or personnel administration. Employee Name:

Personal Information

Position Information

Authorization to Release Information

I hereby authorize any current or former employer, educational institution, business, law enforcement agency, licensing authority, consumer reporting agency, insurance carrier, governmental agency, or other third party to release and disclose to the requesting employer information concerning my employment record, education, credentials, disciplinary actions, worker's compensation claims, and other personnel records as permitted by law. Release To:

Scope of information to be released (check all that apply):

Employment dates and positions held
Wage, salary and payroll records
Performance evaluations, disciplinary records, and attendance
Written or verbal references provided to prospective employers
Claims and separation reasons, including unemployment claims

Background and Consumer Reports Consent

I consent to the procurement of investigative consumer reports, background checks, criminal history checks, and motor vehicle records where relevant and permitted by law. I understand that such reports may include information regarding my character, reputation, driving record, criminal history, and other public records. I authorize the employer to obtain such reports and to provide relevant information to agents, insurers, and regulatory authorities as necessary.

I consent to criminal background and consumer report checks
I consent to obtain driving record / motor vehicle check (if applicable)
I consent to credit checks where job-related and permitted by law

Employment History (Most Recent)

Employment History (Previous)

Education

Professional References

Legal Disclosures

At-Will Employment: Nothing in this Authorization alters the at-will employment relationship between the employee and employer. Either the employee or the employer may terminate employment at any time, with or without cause or notice, except as otherwise provided by law or written agreement.

Equal Opportunity: The employer is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, national origin, age, disability, genetic information, or any other category protected by applicable law.

Applicant Certification and Release

I certify that the information I have provided on this form is true, accurate, and complete to the best of my knowledge. I authorize the release of employment, education, and other records as indicated above. I release from liability any person or entity providing information pursuant to this Authorization and hold harmless the requesting employer and its agents for use of such information. I understand that any misrepresentation, omission, or falsification may be grounds for denial of employment or discipline up to and including termination.

This Authorization shall remain in effect for twelve (12) months from the date of my signature below, unless revoked in writing. I understand I may revoke this Authorization at any time by providing written notice to the requesting employer; however, such revocation will not affect disclosures made in reliance on this Authorization prior to receipt of the revocation.

I certify that all information provided in this form is true and complete.
I authorize the employer to contact previous employers, educational institutions, references, and other listed sources for verification and inquiry purposes.

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