CONSENTTO RELEASE OF INFORMATION

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651

To …………………………
From Personnel Office
A request for certain employment information concerning you has been received from:

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

Please tick below those items of information that you permit us to disclose.

Salary Position
Department Supervisor
Health records

Dates of employment

Part-time/Full-time Hours worked

Whether you work under a maiden name

Wage attachments Reason for redundancy

Other:…………………………………

………………………………………….

Employee Signature  ……………………………                                     Date ………………………

Please return this form to the Personnel Office as soon as possible. Your consent on this occasion will not constitute a consent to release information on future occasions.

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