Employment Information Release Template: Consent and Access

Employment Information Release Template

Employee Name: [Full Name]

Address: [Address]

City, State, ZIP Code: [City, State, ZIP Code]

Email Address: [Email Address]

Phone Number: [Phone Number]

Date: [Date]

Employer or Former Employer: [Company Name]

Department or Contact: [HR / Payroll / Records Department / Other]

Address: [Address]

Authorized Recipient: [Person or Organization Name]

Address: [Address]

Email Address: [Email Address, if applicable]

1. Employee Authorization

I, [Employee Full Name], authorize [Employer or Former Employer Name] to release the employment information described in this document to the Authorized Recipient listed above.

2. Employee Information

Full Name: [Full Name]

Former Name(s), if any: [Name(s)]

Employee ID or Reference Number: [Number, if applicable]

Dates of Employment: [Start Date] to [End Date or “Present”]

Department or Position: [Department / Job Title]

3. Information Authorized for Release

The employer may release the following information:

☐ dates of employment

☐ job title or position history

☐ department or work location

☐ salary or wage information, if permitted by law

☐ attendance or status information

☐ reason for separation, if permitted

☐ performance or evaluation records, if permitted

☐ eligibility for rehire, if permitted

☐ other: [Describe]

4. Purpose of Release

This release is provided for the following purpose:

☐ employment verification

☐ background screening

☐ loan or mortgage application

☐ housing or rental application

☐ government or licensing review

☐ education or training verification

☐ other: [Describe]

5. Method of Disclosure

The authorized information may be released by:

☐ written letter

☐ email

☐ telephone verification

☐ secure portal or electronic system

☐ fax

☐ other: [Specify]

6. Time Period and Expiration

This authorization shall remain effective:

☐ until [Date]

☐ for [Number] days from the date of signing

☐ until the above purpose has been completed

☐ until revoked in writing, to the extent allowed by law

7. Revocation

I understand that I may revoke this authorization by written notice, but any information already released before the revocation may still be relied upon to the extent allowed by law.

8. Employee Acknowledgment

I understand that this release authorizes the disclosure of employment-related information as stated above. I confirm that I am signing this document voluntarily and that the information provided in this form is true and correct to the best of my knowledge.

9. Signature

Employee Signature: __________________________

Name: [Employee Full Name]

Date: [Date]

10. Employer Acknowledgment

Authorized Employer Representative Signature: __________________________

Name: [Full Name]

Title: [Job Title]

Date: [Date]

11. Witness or Notary

Witness Signature: __________________________

Name: [Full Name]

Date: [Date]

Notary, if required:

State of [State]

County of [County]

On this [Day] of [Month], [Year], before me, the undersigned notary public, personally appeared [Name of Signer], known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that they executed the same for the purposes stated herein.

Notary Public Signature: __________________________

Name: [Notary Name]

My Commission Expires: [Date]