Sample Consent Form

CITY OF _________________

Employee Consent for the Release of Personnel Information

As one part of the selection process for <part-time/full-time position title> position, the City of
<Name> will be conducting reference checks. I authorize the City to conduct telephone and/or in
person interviews with individuals familiar with my professional skills and performance. I
understand the City will be contacting both individuals suggested by me and others whom I may
not have mentioned.

I, _____(NAME OF EMPLOYEE OR FORMER EMPLOYEE)_ authorize the City of

____________________________ to disclose to ___(NAME ORGANIZATION SEEKING
INFORMATION ON EMPLOYEE/FORMER EMPLOYEE)___ any and all personnel
information kept by the City of _____________________ with regard to my employment at the
city, including both public data such as wage and benefit information and private data such as my
performance evaluation ratings and any information requested that may be relevant in making a
hiring decision.

I understand that some of my records are protected under state and/or federal privacy laws and
cannot be disclosed without my consent. I expressly release any person in the City of
_______________________ from any and all legal liability for making disclosure of any
information about me, which it is permitted by law, either with my permission or without my
permission, to release.

I also understand that I may revoke this consent at any time except to the extent that action has
been taken in reliance on it and that in any event this consent expires 60 days after it has been
executed

Executed this ___________day of _________________, 20______.

__________________________________________
(Signature of individual authorizing release)

__________________________________________
(Signature of witness)