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Reference Release Form

I authorize The _________ Corporation to seek from all my previous and present schools and employers, and authorize all my previous and present schools and employers to release to The _________ Corporation, any and all information pertaining to my educational and employment history.

If I am offered employment, I also authorize the disclosure to The _________ Corporation of any medical history that may be necessary to verify information provided as a part of the application process.

I release, promise to hold harmless, and covenant not to sue The _________ Corporation on the basis of its attempts to obtain information from my previous and present schools and employers. I release, promise to hold harmless, and covenant not to sue my previous and present schools, employers, or health care providers on the basis of the disclosure of information to The _________ Corporation.

______________________________________
Name of Applicant

______________________________________
Signature of Applicant

______________________________________
Date

Prepared by:
Kollman & Saucier, P.A.
The Business Law Building,
1823 York Road,
Timonium, MD 21093
(410) 727-4300