AUTHORIZATION TO RELEASE WAGE AND EMPLOYMENT INFORMATION AND RELEASE OF LIABILITY

TO:      _______________________________

_______________________________

_______________________________

I,___________________________________________ , hereby authorize

________________________________, my current/former Employer, to release employment references to _______________________________ and their agents, including, but limited to, my entire employment history and wages and any information which may be requested relative to my employment, employment applications, and other related matters, and to furnish any copies of any and all records which you may have concerning me regarding or in connection with my employment.

I further release _________________________ from any and all liability of any kind for releasing any employment information and agree to indemnify and hold _______________________________ harmless for the release of same.

The foregoing authorization shall continue in force until revoked by me in writing.  A photocopy of this authorization shall have the same force and effect as the original.

_______________________________________

S.S. NO:         _____________________________

State Specific Release Forms

—-For State Specific Release Forms you can download in Word Format go to

http://www.uslegalforms.com/waivers/