From: _____________________________




To: _______________________________




I have applied for a position with the following Company: _______________________.


As part of my application, I have been requested to provide information concerning my background and qualifications.  Therefore, I authorize the investigation of my past and present work, character, education, military experience, and employment qualifications by the above Company.


The release in any manner of any and all information by you to the Company indicated above is authorized whether such information is of record or not.  I do hereby release all persons, agencies, firms, companies, etc., from any responsibility for damages resulting  from their provision of such information. 


This authorization is valid for 90 days from the date of my signature below.  Please keep this copy of my release for your files.  Thank you for your cooperation.


Signature: ___________________________          Date: __________________


Witness: ____________________________          Date: __________________



Medical information is often protected by state laws and civil codes.

Consult your attorney if you wish to seek this information.


Note: Many employers are reluctant to provide information on previous employees.  If you ask each prospective employee to distribute this form to his or her references before you contact them, the prior employers may be more willing to release information.