EMPLOYMENT VERIFICATION AUTHORIZATION AND RELEASE FORM

EMPLOYMENT VERIFICATION AUTHORIZATION AND RELEASE FORM

Section I – To be completed by applicant - Please print clearly or type all information
Name

First Name Last Name
Previous Employer
Email
example@example.com
Previous Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Supervisor Name
Title
Telephone No.
Fax No.
I consent to and authorize the above-named former employer, and its agents and employees, to furnish any and all reference
information concerning me to Cedas Home Care Services, LLC within one year of the date of this application, including
achievement, wage history, performance, attendance, personal history, disciplinary information and reason for separation of
employment, relating to my employment with the former employer. I also hereby release the above-named former employer, and its agents and employees, from all liability for damages or claims including, but not limited to defamation, interference with contract, or prospective economic advantage and negligence, I have or may have which arise or result from any reference information provided pursuant to this authorization. I acknowledge that a facsimile or copy of this release shall be as valid as the original.
Signature
Date:

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