• Termination Records Release Form

    Please complete this form to authorize the release of your termination records.
  • Date of Termination
     - -
  • Clear
  • Should be Empty:
Select theme:
  • Default
  • Blue
  • Red
  • Brown
  • Green
  • Black
  • Pink
  • Dark Blue
  • Purple
<\/head>\n
\n
<\/td>\n <\/tr>
\n
\n \"Jotform<\/td>\n <\/tr>
<\/td>\n <\/tr>
<\/td>\n <\/tr>
<\/td>\n <\/tr>
<\/td>\n \n

{form_title}<\/h3>\n <\/td>\n

<\/td>\n <\/tr>
<\/td>\n <\/td>\n <\/td>\n <\/tr><\/table><\/td>\n <\/tr><\/tbody><\/table>
<\/td>\n <\/tr>
<\/td>\n \n
Full Name<\/td>\n \n {fullName}\n <\/td><\/tr>
Date of Termination<\/td>\n \n {dateOf}\n <\/td><\/tr>
Reason for Termination<\/td>\n \n {reasonFor}\n <\/td><\/tr>
Recipient Name (to whom the records will be released)<\/td>\n \n {recipientName}\n <\/td><\/tr>
Recipient Contact Information<\/td>\n \n {recipientContact}\n <\/td><\/tr>
Authorization Signature<\/td>\n \n {authorizationSignature}\n <\/td><\/tr><\/tbody><\/table><\/td>\n <\/td>\n <\/tr>
<\/td>\n <\/tr><\/tbody><\/table><\/td>\n <\/tr>
\n
<\/td>\n <\/td>\n <\/td>\n <\/tr>
<\/td>\n \n You can {edit_submission}<\/span> and {all_submissions}<\/span> easily.\n <\/td>\n <\/td>\n <\/tr>
<\/td>\n <\/tr><\/table><\/td>\n <\/tr>
<\/td>\n <\/tr><\/tbody><\/table><\/div>\n \n <\/body><\/html>\n","branding21Email":"1","dirty":"","dirtyEmail":"1","from":"{fullName}","hideEmptyFields":"1","html":"1","lastQuestionID":"1","name":"Notification 1","pdfattachment":"","replyTo":"{recipientContact}","sendOnEdit":"1","sendOnSubmit":"1","subject":"Re: {form_title} - {fullName}","to":"template+laurelwood@jotform.com","type":"notification","uniqueID":"251921643880056","uploadAttachment":""},{"attachment":"","body":"\n