LETTER-CONSENT FOR INFORMATION RELEASE

I, [YOUR NAME], authorize the [COMPANY/AGENCY NAME] to request information relative to

my educational attainment, previous employment and other personal concerns.

I also authorize any person, educational institution, company, or agency I have indicated in my
Personal Data Sheet as a reference on my employment application to disclose in good faith any
information they may have regarding my qualifications and fitness for employment. I will hold
[COMPANY/AGENCY NAME], any former employers, educational institutions, and any other
persons giving references free of liability for the exchange of this information and any other
reasonable and necessary information incident to the employment process.

I understand that any information released will be held in strictest confidence, that it will be
viewed only by those involved in the hiring decision, and that neither I nor anyone else not so
involved will have the right to see the information. I understand and acknowledge that any offer
of employment is conditional upon [COMPANY/AGENCY NAME] being completely satisfied with
the information provided as a result of this reference check.

[YOUR NAME] [Date]

Applicant