Reference Request Form

Reference Request Form
Reference Type:

EmployerEducational
Reference Name:

First NameLast Name
Employment Dates (From):

MonthDayYear
Date
Employment Dates (To):

MonthDayYear
Date
TO:
Supervisor
Phone:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax:
FROM:
Applicant Name:

First NameLast Name
Position Held:
I HEREBY REQUEST AND AUTHORIZE THE AGENCY TO REQUEST AND RECEIVE FROM ALL PRIOR EMPLOYERS WITHIN ONE YEAR OF THE DATE OF APPLICATION, ANY AND ALL PERTINENT INFORMATION CONCERNING MY PRIOR EMPLOYMENT AND ITS TERMINATION, INCLUDING THE REASONS FOR SUCH TERMINATION. I AGREE TO HOLD HARMLESS THESE PERSONS OR ORGANIZATIONS, THEIR OFFICERS, DIRECTORS, EMPLOYEES, AND AGENTS OF LIABILITY, CLAIMS, DAMAGES, OR DEMANDS OF ANY NATURE ARISING FROM OR RELATED TO THE INVESTIGATION OF INFORMATION CONTAINED IN MY APPLICATION.
Position applied for:
Signature of Applicant:

Clear
Date:

MonthDayYear
Date

FROM: