65104 - Reference Release Form
To gain written permission from the candidate to contact precious employers, and check on the references.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reference 1
Reference Information
Former Employer:
Phone Number:
Position(s) Held:
Dates Employed:
Reference 2
Reference Information
Former Employer:
Phone Number:
Position(s) Held:
Dates Employed:
Reference 3
Reference Information
Former Employer:
Phone Number:
Position(s) Held:
Dates Employed:
Applicants Authorization
I consent to and authorize the above named former employer, andits agents and employees, to furnish any reference information concerning me,including achievement, wage history, performance, attendance, personal history,disciplinary information and reason for separation of employment, relating tomy employment with the former employer. It is expressly understood thatany information given is to be used for the purpose of determining myacceptability for employment. I also hereby release the above named formeremployer, and its agents and employees, from all liability for damages orclaims, including but not limited to defamation, interference with contract, orprospective economic advantage and negligence, I have or may have which ariseor result from any reference information provided pursuant to thisauthorization or any attempts to comply with this information.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: