AUTHORIZATION FOR RELEASE OF INFORMATION

Name of applicant: _________________
Social security number: ____________
Date of application: _______________
Position applied for: ______________


TO: Former Employers, References

You are authorized to release information concerning my employment 
with you, or if you are a personal/academic reference, release 
information concerning my employment/education, including subject 
evaluations to ______________________.

You are further released from liability in connection with your 
response to this inquiry.

A photocopy of this authorization will be as effective as an 
original.


___________________________________________



____________________________
Attention: _________________
____________________________
____________________________
Telephone: _________________