Employment Records Release

EMPLOYMENT RECORDS RELEASE

Applicant Name:   Date of Birth:

Personal Information

Records Requested

Please check the specific categories of employment records you authorize to be released:

All employment records maintained by the entity, including personnel file, withholdings, and correspondence

Employment dates and positions held

Compensation, wage and salary history, bonuses

Performance evaluations, disciplinary records, counseling memos

Attendance, timekeeping, leave records

Benefits enrollment and eligibility records

Background check results and verification responses

Other (describe):

Employer(s) or Record Holder(s)

Designate the employer(s) or entities that hold the records you authorize to be released. Provide as much information as possible to permit accurate retrieval of records.

Purpose and Scope of Release

Purpose of Release:

This authorization covers records generated between: From through .

I understand that this release authorizes the disclosure of records and information described above to the Recipient named below for the stated purpose, and that such information may include confidential personnel records. I further understand that information disclosed pursuant to this authorization may be redisclosed by the Recipient and may no longer be protected by privacy laws.

Recipient / Requesting Party

Education and References

Provide the education and references that may be relevant to verification of credentials.

References (Professional)

Authorization, Certifications and Notices

I hereby authorize the employer(s) and other custodians of my personnel records identified above to disclose the categories of information checked to the Recipient named in this form. This authorization specifically includes release of performance evaluations, disciplinary records, compensation history, and background check results unless otherwise restricted by law.

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that a copy or facsimile of this authorization will be accepted with the same force and effect as the original. I release the employer(s), their agents, and the Recipient from any liability arising from the release or use of information disclosed pursuant to this authorization, provided such disclosure is made in good faith and in accordance with this authorization.

This authorization is voluntary and may be revoked by me in writing at any time, except to the extent that action has already been taken in reliance on it. Unless revoked earlier in writing, this authorization expires on the date specified in the Authorization Period above or 365 days from the date of my signature, whichever occurs first.

I authorize representatives of the Recipient to contact the persons, employers, and educational institutions identified on this form for purposes of verifying the information provided and obtaining records. I understand that such verification may include background screening and criminal record checks if previously indicated above.

Equal Opportunity: The Recipient and employers are governed by applicable equal employment opportunity and privacy laws in their handling of personnel information.

Consent for Background and Records Checks

I consent to the Recipient and its authorized agents performing background checks, employment verifications, education verifications, and criminal history checks as permitted by law. I understand that separate disclosures and notices may be provided where required by law.

Applicant Certification

By signing below I certify under penalty of perjury that the facts set forth in this document are true and correct, and I authorize the release of my employment records in accordance with the terms above.

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