Hiring Manager Rep

STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES

Release of Information

To Whom It May Concern:

I have applied for employment with the Department of Social and Health Services (DSHS), in .

ADMINISTRATION / DIVISION / PROGRAM

As part of the hiring process, the hiring manager or designee must conduct reference checks. The hiring manager or designee may contact references I have not specifically identified. My signature on this document authorizes you to provide an employment reference to DSHS. You may also provide contact information for other individuals or organizations with information relevant to my employment history.

I knowingly and voluntarily release all parties and the state of Washington and the Department of Social and Health Services, including records custodians, current employees and former employees from any and all known and unknown claims for damages or other relief arising out of the department’s request for and receipt of employment reference information. I further release the Department of Social and Health Services from any or all known and unknown claims or damages for relying on the information provided to them through their employment referencing inquiries. This authorization includes review of all employee personnel files, and review of any and all corrective and/or disciplinary actions, regardless of where they are currently located.

I understand this release includes the ability of the hiring manager to contact previous employers I had excluded from contacting on my application.

A photocopy, scanned image, or photograph of this signed authorization is as valid as the original and shall be provided to anyone from whom information related to my work history is requested, if they request a copy. This release will expire 45 calendar days from the date shown below.

Printed Name: Mario B Zelaya

Signature: Date:

FOR IMAGING ONLY

PERSONNEL ID

DOC DATE

SECTION

DOC TYPE

SUB DOC TYPE

HR REP

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Release of Info

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