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City of Eugene <br />Authorization to Release Information to Prospective Employer <br />This authorization is to be completed and signed by the employee. If this authorization is not <br />signed, or if the employee marks the NO box, the City will not provide reference information, <br />except for verifying employment, to prospective employers unless an acceptable subsequent <br />release has been received by the City. <br />I, authorize the City of Eugene and its <br />employees, to release any and all information related to my employment with the <br />City of Eugene, whether such information is favorable or unfavorable to me, to any <br />prospective employer who may inquire about it [or only this specified <br />entity I <br />In addition to authorizing the disclosure of information, i fully waive any <br />rights and claims I have or may have against the City or its employees for releasing <br />information about my employment. I fully release the City and employees from, <br />and promise not to sue concerning, any liability or damage which may result from <br />the disclosure or use of information about my employment with the City. <br />I understand that I may revoke this release in writing by either: (1) sending <br />it to the HR Manager via certified mail, return receipt requested or (2) hand - <br />delivering it to the office of the HR manager and obtaining the signature of the HR <br />Manager or designee acknowledging that the revocation has been received. I <br />understand that any revocation would not be effective as to information released <br />prior to the City of Eugene's receipt of the revocation. <br />YES. I have read this authorization and release, fully understand it, and <br />voluntarily agree to it. <br />NO. I do not wish to sign this authorization and release. I understand that <br />by checking "no," the City will decline to release reference information to <br />prospective employers (other than job title, dates of employment, and other <br />non - evaluative information). <br />Employee's Signature Date <br />http:tl ceshare /cslhrJDocumentslAuthorization_ Release _ Information_to_Prospective Employer. <br />DOC Last updated 1012010 <br />