Authorization to release employment records

Re: <name of employee whose records are being sought>
Date of Birth: <date of birth of employee>
Social Security Number: <social security number>

To: <personnel director or office manager>
<name of company>

I hereby authorize <name of party or parties to acquire employment records> or their agent or representative to inspect, review and make copies, including photostatic copies, of all personnel, employment, medical and payroll records pertaining to <name of employee whose records are being sought>. Photostatic copies of this authorization will be considered as valid as the original.

Dated: _______________

_____________________________________
Employee signature

_____________________________________
Employee name (please print)

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