Personnel Records Release Form

PERSONNEL RECORDS RELEASE FORM

This Personnel Records Release Form (the "Agreement") is made and entered into by and between Employer Name: and Employee Name: on Effective Date:

RECITALS

WHEREAS, Employee is or was employed by Employer and certain personnel records and related information concerning Employee are maintained by Employer; and

WHEREAS, Employee desires to authorize Employer to disclose specified personnel records to Recipient Name: , address , for the purpose described below; and

WHEREAS, Employer requires a written authorization signed by Employee before releasing confidential personnel information.

NOW, THEREFORE, in consideration of the mutual covenants set forth below, the parties agree as follows:

1. AUTHORIZATION TO RELEASE

Employee hereby authorizes Employer and its agents to disclose and release to Recipient the personnel records and information identified in Section 2 below. This authorization expressly permits disclosure to the Recipient named above and to any authorized agent of that Recipient for the stated Purpose.

2. SCOPE OF RECORDS

The records to be released include only those boxes selected below. Check all that apply:

3. PURPOSE

The records shall be released for the following purpose(s):

4. DURATION AND REVOCATION

This authorization is effective as of the Effective Date set forth above and shall expire on Expiration Date: , unless earlier revoked in writing. Employee may revoke this authorization at any time by delivering a signed written notice of revocation to Employer at the Notices address set forth in Section 10. Revocation will not apply to information already released in reliance on this authorization prior to receipt of the revocation.

5. FEES AND COSTS

Employer may charge a reasonable fee for reproduction and shipping of records. The party requesting the records shall be responsible for payment of such fees unless otherwise agreed in writing.

6. RELEASE AND INDEMNIFICATION

Employee hereby releases and forever discharges Employer, its officers, directors, employees and agents from any and all claims, causes of action, liabilities or damages arising from or relating to Employer's disclosure of the personnel records in accordance with this authorization, except to the extent that disclosure violates applicable law. Employee agrees to indemnify and hold Employer harmless from any third-party claims arising from the Employee's failure to authorize release or from false statements made by Employee in this form.

7. CONFIDENTIALITY AND LIMITATIONS

Recipient shall maintain the confidentiality of records received and shall use such records only for the stated Purpose. Recipient may not redisclose the records except as required by law or with additional written authorization from Employee.

8. REPRESENTATIONS

Employee represents and warrants that Employee is the person identified above and has the authority to authorize release of the requested records. Employee further represents that the information provided in this form is true and correct to the best of Employee's knowledge.

9. COMPLIANCE WITH LAW

Employer will comply with applicable federal and state laws governing disclosure of personnel, medical and payroll records. Nothing in this authorization shall require Employer to disclose records that are protected from disclosure by law unless expressly permitted.

10. NOTICES

All notices under this Agreement shall be in writing and delivered to the following addresses:

11. AMENDMENT, WAIVER, COUNTERPARTS

This Agreement may be amended or modified only by a written instrument signed by Employee and an authorized representative of Employer. No failure or delay by either party in exercising any right under this Agreement will operate as a waiver of that right. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

12. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State of , without regard to principles of conflicts of law.

13. ENTIRE AGREEMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior arrangements and understandings. If any provision of this Agreement is determined to be invalid or unenforceable, such invalidity or unenforceability shall not affect the remaining provisions, which shall continue in full force and effect.

ADDITIONAL INFORMATION

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