Information Release Authorization

{{company_name}}

{{company_address}}

Phone: {{phone}} | Email: {{email}} | Web: {{website}}

Information Release Authorization

Information Release Authorization

{{company_name}}

{{company_address}}

{{phone}}

{{email}}

{{website}}

INFORMATION RELEASE AUTHORIZATION

I, {{employee_full_name}}, Employee ID: {{employee_id}}, hereby authorize {{company_name}} (hereinafter referred to as "the Company") to release the following information about me, as specified below, to the designated third party.

Date of Birth: {{employee_dob}}

National ID/Passport Number: {{employee_national_id}}

Contact Number: {{employee_phone_number}}

Email Address: {{employee_email_address}}

Purpose of Information Release

The information is being released for the following specific purpose(s): {{purpose_of_release}}.

Information to be Released

I authorize the release of the following specific information (check all that apply):

☐ Employment dates (start and end date): From {{employment_start_date}} to {{employment_end_date}}

☐ Job title(s): {{job_titles}}

☐ Salary/wage information: Basic Salary: {{basic_salary}}, Allowances: {{allowances}}

☐ Performance reviews/records: {{performance_review_details}}

☐ Disciplinary records: {{disciplinary_record_details}}

☐ Reason for separation (if applicable): {{reason_for_separation}}

☐ Other (please specify): {{other_information_to_release}}

Designated Third Party

The information is to be released to the following individual/organization:

Organization Name: {{third_party_organization_name}}

Contact Person: {{third_party_contact_person}}

Address: {{third_party_address}}

Phone Number: {{third_party_phone_number}}

Email Address: {{third_party_email_address}}

Duration of Authorization

This authorization is valid from {{start_date_of_authorization}} until {{end_date_of_authorization}} or until explicitly revoked in writing by me. If no end date is specified, this authorization remains valid for {{number_of_days_or_months}} days/months from the date of my signature below.

Revocation of Authorization

I understand that I have the right to revoke this authorization at any time by providing written notice to the Company's HR Department. Such revocation will not affect any disclosures made prior to the Company's receipt of my written revocation.

Confidentiality and Indemnity

I understand that once my information is disclosed to the designated third party, it may no longer be protected by the Company’s privacy policies. The Company will not be held liable for the use or misuse of the information by the designated third party. I hereby release and hold harmless {{company_name}}, its officers, employees, and agents from any and all liability, claims, or damages resulting from the release of information requested herein.

Employee Declaration

I declare that I have read and understood the terms of this Information Release Authorization and voluntarily consent to the release of my information as described above.

Employee Full Name: {{employee_full_name}}

Employee Signature: _________________________ Date: {{signature_date}}

Company Representative (Witness)

I, the undersigned Company Representative, witness the above signature as genuine.

Company Representative Name: {{company_representative_name}}

Company Representative Title: {{company_representative_title}}

Company Representative Signature: _________________________ Date: {{witness_signature_date}}