Connecticut Applicant Information Release


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                             This Applicant Information Release form is used by an employer for the purpose of eliciting
                             information about an applicant from former employers, educational institutions, and
                             personal references listed by the applicant in the application for employment. This form is
                             useful for employers located in Connecticut when checking references supplied by potential
                             employees. Many references will ask for a release before providing information, in order to
                             protect themselves from any potential liability that may arise from disclosing information
                             regarding the applicant. This release notifies the references that the applicant has
                             consented to the release of such information.

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                                  APPLICANT INFORMATION RELEASE

This Agreement is made and effective on this ____ [Month] ____ [Date], 20____, by and between
_____________________________   [Instruction:   Insert     the    name      of    employee],      located   at
__________________________________________ [Instruction: Insert the address of the employee]
("Employee") and _____________________________ [Instruction: Insert the name of company], with a
place of business at _______________________________ [Instruction: Insert the address of the company]
("Company ").

In connection with my application for employment with the Company. I hereby agree as

I hereby authorize any person, educational institution, or company I have listed as a reference on my
employment application to disclose in good faith any information they may have regarding my
qualifications and fitness for employment. I will hold __________ [Instruction: Insert the name of
company], any former employers, educational institutions, and any other persons giving references
free of liability for the exchange of this information and any other reasonable and necessary
information incident to the employment process.

   For: EMPLOYEE                                         For: COMPANY

   Signed:_________________________________              Signed:_______________________________

   Name:                                                 Name:

   Date:                                                 Date:

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