Authorization To Obtain Employment And Reference Information And/or Review Personnel File Of Employment Applicant printable pdf download

SAMPLE

AUTHORIZATION TO OBTAIN EMPLOYMENT AND REFERENCE INFORMATION

AND/OR REVIEW PERSONNEL FILE OF EMPLOYMENT APPLICANT

Name of Applicant: ______________________________________________________

Social Security Number (current civil service employees only): _______-_____-_______

I have applied for a position as a ___________________________ with the Department

of ________________________. As part of the employment selection process, I hereby

authorize a representative of the department to:

Conduct an employment reference check by asking references I

identified, my former employer(s), coworkers and/or educators about my ability to

perform my duties, interact with coworkers, management and the public, and any other

aspect of my past or current employment;

Verify information I have provided in my employment interview or on my

job application;

Examine, inspect and/or copy any records reflecting my employment

history, including records of my education, personnel history, supervisory, official

personnel folder or organizational files relating to my application for employment; and;

Any and all other information requested regarding my current or previous

work.

In signing below, I understand that the documents to be reviewed will contain information

regarding my education and employment history and may include such items as payroll

records, employment history, prior performance evaluations, attendance records,

commendations, disciplinary actions, corrective actions, grievances, health records, or

appeals and other material relating to my employment. A photocopy of this authorization

shall be as valid as the original. Any information obtained through this authorization

shall be kept confidential by the department performing this reference.

This authorization is valid for 90 calendar days from the date of signature.

_________________________________________________

________________

Applicant’s Signature

Date

_________________________________________________

________________

Signature of Individual(s) obtaining and reviewing information

Date

PRIVACY STATEMENT

This information is requested by the State of California. The Information Practices Act of 1977 (California

Civil Code Section 1798.17) and the Federal Privacy Act (5 USC 552a, subdivision (e)(3); require this notice

be provided when collecting personal information from individuals. Information requested on this form,

which includes the social security number is needed by human resource staff to identify applicants

accurately. Furnishing the requested information on this form is mandatory. Failure to provide this

information will prevent the hiring division/unit from obtaining crucial information needed during the hiring

process, and will affect the potential employee’s chances for hire.

Purpose

Authorization To Obtain Employment And Reference Information And/or Review Personnel File Of Employment Applicant