Release R02 Permission to Release Files Candidate: ___________________________ ___________________________ _____________________ First Middle Last Address: ___________________________________ ____________________ ______ ______________ Street City State Zip Best Contact # (________) ____________ ‐ _____________ [__] Cell [__] Home [__] Work Email: _______________________________________________________________________________ District: [__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR Acknowledgement: By signing below, I hereby give permission for the following documents in my file to be released electronically to the person(s) listed below. Documents to Release: (Initial to indicate permission) [____] Background Check [____] Credit Check [____] Psychological Report [____] Medical History Form Authorized to release documents to: ____________________________________________________________ First and Last Name Company: _____________________________________ Phone: (_______) ___________ ‐ _____________ [__] Cell [__] Home [__] Work Email: Documents to Release: (Initial to indicate permission) [____] Background Check [____] Credit Check [____] Psychological Report [____] Medical History Form Authorized to release documents to: ____________________________________________________________ First and Last Name Company: _____________________________________ Phone: (_______) ___________ ‐ _____________ [__] Cell [__] Home [__] Work Email: Documents to Release: (Initial to indicate permission) [____] Background Check [____] Credit Check [____] Psychological Report [____] Medical History Form Authorized to release documents to: ____________________________________________________________ First and Last Name Company: _____________________________________ Phone: (_______) ___________ ‐ _____________ [__] Cell [__] Home [__] Work Email:
__________________________________ __________________________________ ___________________ Signature Printed Name Date
Copies of this Release are to be placed in the Candidate’s DCOM file and the Conference Secretary’s file: [__] Chair, DCOM [__] Conference Secretary via conferencesecretary@holston.org
Updated: 2020‐11