Employment Reference With Consent and Release*
Applicant: Please complete only through your signature. Do NOT send this to your employer(s).
A reference will be requested from your employer(s) by Human Resources or the hiring supervisor.
___ , (Print Name of Applicant) SSN: ______ __I,
hereby give consent to all of my prior employers, and my current employer if authorized, to provide Harding
University the information below with regard to my employment with the prior or current employers. This consent
is valid for a period of six (6) months from the date indicated below. A copy of this form shall serve as an original.
Signature of Applicant:
*****The following is to be completed by the current or former employer.*****
Instructions: The individual named above has applied for employment with Harding University. Please
respond candidly to the requests for information listed below and return your written responses via either
facsimile or U.S. Mail. This Employment Reference With Consent and Release is intended to comply with
Arkansas Act 1474 of 1999, an Act to provide current and former business employers with protection for
providing job information about current or former employees to prospective employers.
Previous or Current Employer Address
______________________________________, _____________________________ ________________
City State ZIP Code
Phone: ( ) Fax: ( ) _____________________________
Completed by: __________________________ _ _________________________________________
Signature Date Print Name
Is the applicant eligible for rehire? _____Yes _____No _____Conditional (attach explanation)
Date and duration of employment:_____________________________________________________________
Current or last rate of pay and wage history:_____________________________________________________
Current or last job description and duties: ______________________________________________________
The details of the applicant’s last written performance evaluation prepared prior to the date the applicant
signed this consent (see date above): _________________________________________________________
Attendance history (excluding any qualifying leave under FMLA): ____________________________________
Results of drug and/or alcohol tests administered within the last year: ________________________________
Details of any threats of violence, harassing acts, or threatening behavior related in any way to the workplace
or directed at another employee: _____________________________________________________________
Was his/her separation from employment _____ voluntary _____ involuntary?
What was the reason for the applicant’s separation from employment? _______________________________
Please Return to:
Office of Human Resources
Harding University, Box 12257, Searcy, AR 72149-2257
Phone: 501-279-4380 Fax: 501-279-4773