I hereby authorize the recipient of this authorization to release any information, whether confidential or not, requested by ____________________________which could relate to my employment with them. I further authorize you to candidly disclose all facts and opinions concerning my work performance, cooperativeness, and ability to get along with others. I release you from any and all liability for your responses to questions by them.

A copy of this authorization is as valid as the original.

This authorization shall remain in force for 90 days from the date below.






Printed Name:__________________________________________


Residential address:_________________________________________________________