Revised October 2015
Employee Authorization to Release Records
I understand and agree that: The information supplied, was submitted by myself, and all information is
true and correct, to the best of my knowledge. I understand that false or misleading information given in
my application and/or interview(s) will be considered as cause for possible dismissal and/or discharge. I
also understand that I am to abide by all rules and regulations of the company. The company has my
authorization to thoroughly investigate my work and personal history. I understand that the information
supplied by me, regarding my: Employment History, Education (including an authorization to release
transcripts), Criminal History, Medical and Professional Licensing, and References, will be utilized as
part of the processing procedures. A background check will be conducted to verify the authenticity of the
information submitted and will be utilized to develop information concerning my character, general
reputation, and personal characteristics. I will hold no person liable for giving or receiving information in
this investigation. I hereby authorize North Carolina Wesleyan College to make a thorough check of my
past Employment, Education, and activities. I release from liability all persons, companies, and
corporations supplying that information. I release and indemnify North Carolina Wesleyan College and
any company or service they select against any liability that might result from making such background
checks. A copy of this form is as valid as the original.
EMPLOYEE/APPLICANT INFORMATION:
____________________________ ________ ________________________________
First Name MI Last Name
________________-_________-___________________
Social Security Number
______________/___________/_____________
Date of Birth
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PLEASE NOTE WE NEED AN “ACTUAL SIGNATURE” BELOW NOT A TYPED ONE.
Please print this page and scan it as an attachment when submitting your package.
__________________________________________ ________________________
Signature Date
