Information Release Authorization

{{company_name}}

{{company_address}}

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

Information Release Authorization

Information Release Authorization

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

INFORMATION RELEASE AUTHORIZATION

Date: {{date}}

SECTION 1: EMPLOYEE INFORMATION

Employee Name: {{employee_full_name}}

Employee ID: {{employee_id}}

Department: {{department}}

Contact Number: {{employee_phone}}

Email Address: {{employee_email}}

SECTION 2: RECIPIENT INFORMATION

Recipient Name: {{recipient_name}}

Organization/Company: {{recipient_organization}}

Relationship to Employee (e.g., prospective employer, financial institution): {{recipient_relationship}}

Recipient Address: {{recipient_address}}

Recipient Phone: {{recipient_phone}}

Recipient Email: {{recipient_email}}

SECTION 3: INFORMATION TO BE RELEASED

I, {{employee_full_name}}, hereby authorize {{company_name}} to release the following information about me to the recipient named in Section 2:

Please tick all applicable boxes:

☐ Employment dates (Start and End): {{employment_dates}}

☐ Job Title(s) and Responsibilities: {{job_titles_responsibilities}}

☐ Salary/Compensation Information: {{salary_compensation}}

☐ Performance Reviews/Appraisals: {{performance_reviews}}

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

☐ Attendance Records: {{attendance_records}}

☐ Disciplinary Records: {{disciplinary_records}}

☐ Educational Qualifications as per company records: {{educational_qualifications}}

☐ Professional Licenses/Certifications: {{professional_licenses}}

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

SECTION 4: PURPOSE OF INFORMATION RELEASE

The information specified above is being released for the following purpose:

{{purpose_of_information_release}}

SECTION 5: DURATION OF AUTHORIZATION

This authorization is valid from {{start_date_of_authorization}} until {{end_date_of_authorization}} or until revoked by me in writing, whichever comes first.

In the absence of a specified end date, this authorization will be considered valid for a period of {{number_of_days_or_months}} {{days_or_months}} from the date of my signature below.

SECTION 6: REVOCATION OF AUTHORIZATION

I understand that I have the right to revoke this authorization at any time by providing written notice to {{company_name}}. Such revocation will not affect any disclosures made prior to the receipt of my written revocation.

SECTION 7: RELEASE OF LIABILITY

I hereby release and hold harmless {{company_name}}, its officers, employees, and agents from any and all liability, claims, or causes of action arising from the disclosure of the information authorized herein, provided such disclosure is made in good faith and in accordance with the terms of this authorization. I understand that the recipient of this information may not further disclose the information without my prior written consent, unless otherwise permitted by law.

SECTION 8: EMPLOYEE DECLARATION AND SIGNATURE

I confirm that I have read and understood the terms of this Information Release Authorization. I voluntarily provide this consent for the release of my information as specified above.

_________________________________________

Employee Full Name: {{employee_full_name}}

Signature: ______________________________

Date: {{signature_date}}

SECTION 9: COMPANY REPRESENTATIVE ACKNOWLEDGMENT (Optional)

Acknowledged by:

_________________________________________

Company Representative Name: {{company_representative_name}}

Title: {{company_representative_title}}

Signature: ______________________________

Date: {{acknowledgment_date}}