Name of applicant: Enter the name of the applicant

Social security number: Enter the social security number of applicant

Date of application: Enter the date of the application

Position applied for: Enter the position applied for

TO: Former Employers, References

You are authorized to release information concerning my employment with you, or if you are a personal/academic reference, release information concerning my employment/education, including subject evaluations to Enter the name of prospective employer.

You are further released from liability in connection with your response to this inquiry.

A photocopy of this authorization will be as effective as an original.

___________________________________________

Enter the name of the applicant

Enter the name of prospective employer

Attention: Enter name of person to reply to at employer

Enter the street address of the prospective employer

Enter the city, state of the prospective employer

Telephone: Enter the telephone number of prospective employer