Employment Verification Request Form
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1Employment Verification Request Form
Human Resources-Records
Employment Verification: The Division of Human Resources Records office will only release general employment
information for verification purposes. Signed authorization from the individual in question is required for the release of
employment information. Requests are processed within 1-2 business days from date received, unless further research is
required.
Please complete Sections I and II.
Employment Letters: At the request of the employee, HR Records will prepare an official letter of employment, limited to two
originals. Twenty-four hours advanced notice is required. The letter will include the employee’s date of employment, position
title, and department name. Salary can be included by request only.
Please complete Section I.
I am requesting:
Employment Verification
[ ] or
Employment Letter
[ ]
Return by (please check one):
Fax
[ ]
Mail
[ ] or
In Person Pick-up
(for employment letter only, employee must show ID) [ ]
SECTION I – To be completed by employee
I hereby authorize GRU/GRMC HR Records to release my current or previous employment information. Additionally, I release
Georgia Regents University/Georgia Regents Medical Center from all liability whatsoever for issuing the requested information.
Employment Status:
Currently Employed
[ ]
Previously Employed
[ ]
Provide Salary Information
[ ]
_____________________________________________
_____________________________________________
Print Name
Employee ID or Last 4 of Social Security Number
_____________________________________________
_____________________________________________
Signature
Date
SECTION II – I authorize GRU/GRMC to release employment information to:
_________________________________________________________
_________________________________________
Company or Institution Name
Phone/Fax Number
_______________________________________________________________________________________________________
Contact Name and Title
_______________________________________________________________________________________________________
Complete Mailing Address
SECTION III – To be completed by GRU/GRMC HR Records Representative
I certify that the personnel records of Georgia Regents University/Georgia Regents Medical Center reveal the following
information on the current or former employee as indicated above in Section I. Please note: performance information will not be
provided.
Employment Dates: ______________________________________________________________________________________
Position Title: ____________________________________________________________________Full-time [ ] or Part-time [ ]
Other: _________________________________________________________________________________________________
(please specify any additional requested information for consideration)
_______________________________________________________________________________________________________
Printed Name/Title of Records Representative Completing Request
_________________________________________________________________
Date: __________________________
Signature of Records Representative Completing Request
HR Records Use Only:
GRU/GRMC
1120 Fifteenth Street, HS-1115
Date Received & Logged: __________________________
Human Resources-Records
Augusta, Georgia 30912
Date Completed & Returned: _____________________
Phone: (706) 721.3631, Fax: (706) 721.2899
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Parent category: Legal