SECURING AND PROVIDING EMPLOYMENT REFERENCE INFORMATION
SAMPLE RELEASE

TO:	(Name of former employer/educational institution, etc.)
	(Mailing address)
ATTENTION: 

BY:	(Applicant's name)

	I am being considered for employment with the (Department/Division name), State of West Virginia.  As a condition for further employment consideration, I have consented to an initial screening conducted by them.

	The (Department/Division name) may request all information it deems relevant to my eligibility to hold such a position from the above named person or firm which has been given by me as a reference.  Further, I authorize the listed reference to disclose to the (Department/Division name) the appropriate responses to the attached questions.  I authorize all former employers, educational institutions, governmental entities, or persons to release all legally permissible information in their possession which may be related to me to the (Department/Division name).

	I hereby waive any privilege of confidentiality with respect to any such information.

	A photocopy of this authorization shall be considered as effective and valid as the original and shall remain on file at the (Department/Division name).  Please provide the requested information within 10 days of the date of this letter so that I may receive further consideration for which I am applying.

SIGNATURE _____________________________________   DATE ___________________