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sample reference check release

The following is sample language student employees and graduate assistants can use to authorize the release of their employment information for job references. A signed release from the graduate assistant or student employee is required before a department can provide a reference.


Full Name: _______________________________________________

I, ____________________________, hereby authorize ___________________ (Department) of Michigan State University to release job reference information, including the dates of employment, job duties, and quality of my performance to (check which applies):

_______any prospective employers who request the information for hiring purposes.

_______only these prospective employers:  ____________________________________________________________

I understand this information is considered a student record. Further, I understand that by signing this release, I am waiving my right to keep this information confidential from the above personnel under the Family Educational Rights and Privacy Act (FERPA).

I certify that my consent for the release of this information is entirely voluntary. I certify that I understand this consent to release can be revoked by me at any time in writing but will not be effective for materials already released under it.

Student Signature: ____________________________ Date: __________