Authorization to Release Employment Information
Company
to
receive
information:
Name
of
contact
person:
Street
address:
City,
state
&
zip
code:
Phone
&
fax:
You must sign this authorization before employment verification information may be disclosed to the
company named above.
I authorize the District of Columbia Public Schools (DCPS), including any of its employees or
subcontractors, and other District of Columbia agencies, including such agencies’ employees or
subcontractors, to disclose the following information regarding my employment at DCPS to the company
named above: salary, job title and dates of employment. In addition, I authorize disclosure of the
following information:
I release DCPS, the District of Columbia and all of their employees and subcontractors from all liability
whatsoever resulting from such disclosures.
I AUTHORIZE A PHOTOCOPY OF THIS RELEASE TO BE ACCEPTED WITH THE SAME AUTHORITY AS THE
ORIGINAL AND IF EMPLOYED BY THE ABOVE NAMED COMPANY THIS RELEASE WILL REMAIN IN EFFECT
THROUGHOUT SUCH EMPLOYMENT.
Last Name First Name Middle Name
Street Address
City State Zip Code
Signature Date Social Security Number Employee ID (if applicable)
1200 First Street, NE | W ashington, DC 20002 | T 202.442.4090 | F 202.442. 5315 |
www.dcps.dc.gov
click to sign
signature
click to edit
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