4/1/2011@BCL@7405AC79.rtf
SAN LEANDRO UNFIED SCHOOL DISTRICT
HUMAN RESOURCES
AUTHORIZATION TO ACQUIRE INFORMATION FROM REFERENCES
THIS AUTHORIZATION MUST BE SUBMITTED WITH YOUR APPLICATION
It is the policy of San Leandro Unified School District to conduct reference checks for all candidates for
employment. Reference checking is generally conducted after the interview portion of the selection procedure,
and three references are normally obtained before the candidate is offered employment. Occasionally the
District conducts reference checks prior to inviting candidates to participate in an interview.
Your signature below indicates your agreement with and acknowledgment of the following:
As an applicant for an employment position with San Leandro Unified School District, I authorize my current
and past employers and work associates, including, but not limited to supervisors, colleagues, and subordinates
to release to the San Leandro Unified School District any reference information in my personnel records or file
(including but not limited to applications for employment, sick leave records, performance evaluations),
academic records (including but not limited to transcripts, certificates, credentials, etc.), and information related
to my work-related personal characteristics (including but not limited to, my character, dependability, honesty,
integrity, ability to work under pressure, interpersonal skills, general physical ability, and reputation, among co-
workers.)
I expressly and without reservation waive my right to review the information collected in the reference checks.
The San Leandro Unified School District will maintain reference information in strictest confidence and solely
for purpose of evaluating my qualifications for position. Information obtained during reference checks will not
be provided to anyone outside the selection process.
A photocopy of this signed authorization is to be considered valid as an original.
IN EXECUTING THIS AUTHORIZATION, I FULLY AND COMPLETELY RELEASE ALL PRESENT AND PAST
EMPLOYERS AND THEIR EMPLOYEES, THE SAN LEANDRO UNIFIED SCHOOL DISTRICT AND ITS
EMPLOYEES, AND ALL OTHER PERSONS AND ENTITIES FROM LIABILITY FOR ANY DAMAGE, INCLUDING,
TO THE FULL EXTENT ALLOWED BY LAW, LIABILITY UNDER CALIFORNIA CIVIL CODE SECTIONS 45 AND 46
AND CALIFORNIA LABOR CODE SECTION 1054, OR ANY SIMILAR LAWS OF OTHER STATES OR POLITICAL
ENTITIES, WHICH MAY RESULT FROM FURNISHING INFORMATION WHICH I AM PERMITING TO BE
RELEASED BY WAY OF THIS AUTHORIZATION.
I HAVE CAREFULLY READ AND UNDERSTAND ALL OF THE PROVISIONS OF THE AUTHORIZATION. AND
HAVE VOLUNTARILY AND WITHOUT COERCION OR DURESS AGREED TO AND SIGNED THIS
AUTHORIZATION.
________________________________________________ ____________________________________
Candidate’s full name (Print) Other last names you have used (if any)
________________________________________________ ____________________________________
Candidate’s signature Date
SAN LEANDRO UNIFIED SCHOOL DISTRICT
APPLICANT’S DATA RECORD
Qualified applicants are considered for all positions. The San Leandro Unified School District is
committed to equal opportunity and does not discriminate in any program or activity on the basis of sexual
orientation, actual or perceived sex, gender, ethnic group identification, race, ancestry, age, color, religion,
national origin, ethnic group, marital or parental status, physical or mental disability, or on the basis of a
person’s association with a person or group with one or more of these actual or perceived characteristics, in
accordance with the provisions of Title VI and Title VII of the Civil Rights Act, Title IX of the Education
Amendments of 1973, Section 504 of the Rehabilitation Act of 1973, Education Code 200 and 220, and
California Government Code 512490 and 11135. However, Federal and State Fair Employment Laws permit
the completion of pertinent data to comply with federal guidelines and regulations, and such information
may be solicited voluntary and used for statistical purpose. Information provided will assist the District
in accurately compiling required statistical reports for federal and state agencies. Appropriate safeguards
are mandated to guard against misuse or violations in this regard; therefore, a separate, confidential file
will be established for these forms and none of the information will be used to discriminate or give
preference to any individual in any personnel transaction. To help us comply with government
recordkeeping, please fill out this Data Record Form.
Name: _________________________________________ Phone:__________________________
Address: ____________________________________________________________________________
Number Street
____________________________________________________________________________
City State ZIP
_____________________________________________________________________________________
Check one: [ ] Male [ ] Female
Check one of the following Ethnic Groups:
[ ] Hispanic or Latino of any race [ ] Non Hispanic or Latino of any race
Check as many Races as apply:
[ ] Chinese [ ] Cambodian [ ] Samoan [ ] African American
[ ] Japanese [ ] Hmong [ ] Tahitian
[ ] Korean [ ] Other Asian [ ] Other Pacific Islander
[ ] Vietnamese [ ] Pacific Islander [ ] Filipino
[ ] Asian Indian [ ] Hawaiian [ ] White
[ ] Laotian [ ] Guamanian [ ] American Indian or Alaskan
COMMENTS: _______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
AN EQUAL OPPORTUNITY EMPLOYER
File:///Laura/Microsoft Office 98 / Applicant’s Data Record: HR/1/02/lg Last Edited on 4/1/2011
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