Release of Information Form Date: ________________________ To: _________________________ Name: _______________________ Social Security Number: _______-_______-_______ We have been given permission to obtain a copy of the personnel information on the above mentioned applicant. Please provide the following information to the best of your knowledge: Date of Hire: _____________________ Date of Employment Terminated _________________ Reason for Leaving: ____________________________________________________________ Reliable: Yes ______ No_______ Attendance: Good _______ Poor _______ Eligible for rehire: Yes ______ No______ Please ______________________ the requested information to our office at the address listed below. (Fax or Mail) I authorize you to release any and all personnel information. _______________________________ __________________________ Applicant’s Signature Date _______________________________ __________________________ Agency’s Signature Date
Release of Information Form Date: ________________________ To: _________________________ Name: _______________________ Social Security Number: _______-_______-_______ We have been given permission to obtain a copy of the personnel information on the above mentioned applicant. Please provide the following information to the best of your knowledge: Date of Hire: _____________________ Date of Employment Terminated _________________ Reason for Leaving: ____________________________________________________________ Reliable: Yes ______ No_______ Attendance: Good _______ Poor _______ Eligible for rehire: Yes ______ No______ Please ______________________ the requested information to our office at the address listed below. (Fax or Mail) I authorize you to release any and all personnel information. _______________________________ __________________________ Applicant’s Signature Date _______________________________ __________________________ Agency’s Signature Date