rev 5/8/2018
APPLICANT DATA/REFERENCE RELEASE FORM
SECTION I:
In the event that you are considered a finalist for the position, please indicate if we may contact your supervisors or
references listed on your application or listed below. If you do not provide permission and reference information, your
references will not be contacted. However, the lack of reference information may be considered in the selection decision.
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IGNATURE OF APPLICANT DATE
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RANTING PERMISSION TO CONTACT REFERENCES
In order to obtain meaningful reference information from some employers it is useful to have a release which assures the
former employer/reference that you will not pursue litigation against them based on their reference information. Your
references will be contacted if you provide permission above, even if they are not released from potential liability.
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IGNATURE OF APPLICANT DATE
R
ELEASING REFERENCES FROM LIABILITY FOR REFERENCE INFORMATION
SECTION II:
REFERENCE NAME RELATIONSHIP TO REFERENCE PHONE NUMBER
(S
UPERVISORS ARE PREFERRED)
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EFERENCE NAME RELATIONSHIP TO REFERENCE PHONE NUMBER
(S
UPERVISORS ARE PREFERRED)
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EFERENCE NAME RELATIONSHIP TO REFERENCE PHONE NUMBER
(S
UPERVISORS ARE PREFERRED)
SECTION III.
Do you have any reason to believe that any of your references may provide negative information? If so, you may explain
orally now or provide in writing on the back of this page with an explanation to the Selecting Official within 3 business
days of this interview.
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