Education And Employment Verification Authorization Form Page 2
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2Education and Employment
Verification Authorization Form
Name of Employer: ___________________________________ Telephone: _____________
Employed from: ________________________ to: __________________________
Job Title: _____________________________ Eligible for Rehire: Yes
or No
Verified with: ___________________________________________________________
(Name and Title)
Name of person conducting this verification: ___________________ Date: ___________
Name of Employer: ___________________________________ Telephone: _____________
Employed from: ________________________ to: __________________________
Job Title: _____________________________ Eligible for Rehire: Yes
or No
Verified with: ___________________________________________________________
(Name and Title)
Name of person conducting this verification: ___________________ Date: ___________
REFERENCE CHECK PERMISSION
I authorize Northeastern University to conduct a reference check with my present and/or previous employer(s). This also
serves to authorize my present and/or previous employer(s) to provide reference information to Northeastern University as
it is requested. I understand that reference information may include, but not be limited to, verbal and written inquiries or
information about my employment performance, professional demeanor and character, rehire potential, dates of
employment, salary and employment history. By providing such authorization, I understand and agree that I release
Northeastern University, its trustees, faculty, staff, employees and agents, from any and all claims or potential claims I
may have regarding any and all information released to or by Northeastern University and regarding any employment
decisions made about me on the basis of such information.
Candidate’s Name (print): __________________________________ Date: _____________
Signature: __________________________________
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