Employee Reference Request Consent Sample Form


I request ______________________________ to serve as a reference for me for the purpose of obtaining employment.

The reference may be given in the following form/s (check one or both spaces):

_____ written

_____ oral

I authorize the above person to release information and provide an evaluation about any and all aspects of my job performance at the University of Minnesota to:

_____ all prospective employers

_____ specific employers (list below)

 

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____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

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This authorization to provide references is valid for one (1) year from the date of my signature below, unless I specify an earlier ending date as follows:


Ending date: ___________________________

Employee Name (print): ___________________________

 

__________________________ __________________________
Employee Signature Date