Employment Score Verification - EIPA
Section 1: Test Candidate Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Record ID (if known)
Date of EIPA Test Taken
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Section 2: Organization Requesting Verification
Organization Name
*
Contact Name & Title
*
Contact Email
*
Contact Phone
*
Section 3: Scope of Authorization
I authorize the EIPA Diagnostic Center to disclose the following information about my EIPA assessment results to the organization named above (check all that apply):
*
My specific performance level/score result
The date I tested
Confirmation of authenticity of a specific score report (attach copy of report)
Other (describe below)
Other - describe
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Section 4: Authorization Terms
By signing below, I authorize the EIPA Diagnostic Center to release the information indicated in Section 3 to the organization named in Section 2. I understand that:
*
This authorization is valid for forty-five (45) days from the date signed, or for a single response to the specific request described above, whichever occurs first.
I may revoke this authorization at any time by written notice to EIPA prior to EIPA's response being sent.
EIPA will retain a copy of this form and its response for its records per standard retention policy.
Section 5: Test Candidate Signature
Signature
*
Test Candidate Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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