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