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Employee Information Release Form
Personal Information
Applicant Name: ______________________________
Date of Filing: ______________________________
Department: ______________________________
Position Title: ______________________________
Employment ID #: ______________________________
Type of Information to Release
Work History
Start and End Dates
Evaluations
Disciplinary Records
Benefits Information
Other: ______________________________
Authorized Personnel/Companies to Receive Aforementioned Information
Name #1: ______________________________
Address #1: ______________________________
Phone #1: ______________________________
Email Address: #1: ______________________________
Name #2: ______________________________
Address #2: ______________________________
Phone #2: ______________________________
Email Address: #2: ______________________________
I, the undersigned, do hereby swear that the aforementioned information is true and factual to the best of my knowledge. I authorize {Company/Contacts} to release the checked information to the aforementioned personnel.
______________________________
Applicant Signature
______________________________
Date Signed
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