Fill in the name on the person you want records for on the "(name of person signing)" line and fill your name and address in the "release to" section. Have the person you want records for mail or FAX the completed form into the employer(s) you want records from. This form may also be modified to include specific records if necessary.
AUTHORIZATION FOR RELEASE OF EMPLOYMENT RECORDS
(name of person signing)
City: ________________________, State ________
SS#: ________________________, DOB __________________