Authorization to Release Information

Date:

To: ________________________

Please be advised that I have applied for a position with I have been requested to provide iniormation for their use in reviewing my background and qualilications. Therefore, I authorize the investigation of my past and present health, character, education, military and employment qualifications.

The release in any manner of all information by you is hereby authorised whether such information is of record or not, and I do hereby release all persons, agencies or firms from any liabilities resulting from providing such information.

This authorisation is valid œor________________ days from the date of my signature below. Please keep this copy of my release request for your files.

We thank you for your cooperation.

______________________

Signature

Witnessed by: _______________________