4052 FORM

Job References to Prospective Employers

For Current and Former Employees

CONSENT TO PROVIDE EMPLOYMENT HISTORY

TO PROSPECTIVE EMPLOYERS

I, __________________________ (applicant), consent to any and all of my former employers to provide information regarding my employment to any prospective employer(s) who contact them.

I consent to the disclosure of the following information about me by any and all of my former employers:

1. Date and duration of employment;

2. Pay rate and wage history on the date of receipt of this consent;

3. Job description and duties;

4. The most recent written performance evaluation prepared prior to the date of the request for information and provided to me during the course of my employment;

5. Attendance information;

6. Results of drug or alcohol tests administered within one year prior to the request for information;

7. Threats of violence, harassing acts, or threatening behavior related to the workplace or directed at another employee;

8. Whether I was voluntarily or involuntarily separated from employment and the reasons for the separation; and

9. Whether I am eligible for rehire.

The consent is valid for six months from the date of my signature below.

______________________  ____________________     ____________

Printed Name                             Signature                                     Date