Free Legal Forms
| Authorization for Release of Information |
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Name of applicant: _________________ Social security number: ____________ Date of application: _______________ Position applied for: ______________ TO: You are authorized to release information concerning my employment with you, or if you are a personal/academic reference, release information concerning my employment and education, including subject evaluations to ______________________. You are further released from liability in connection with your response to this inquiry. A photocopy of this authorization will be as effective as an original. ___________________________________________ Requester Please send it to the following person. ________________________ Attention: _________________ ____________________________ ____________________________ Telephone: _________________ If there are any charges connected with this transaction, please charge: My Credit Card Number: Expiration Date: Exact Name on Card: If you require a check, please contact me at the above address, by fax, email, or phone, and I will send one forthwith. I hereby authorize the charges for this service. ____________________ Date: Requester Please email, fax, or phone me to confirm you have completed this transaction. Many thanks in advance for your assistance, ____________________ Date: Requester |
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