Quick Links

Skip to main content Skip to navigation

Main Navigation


Board Policies

Home > breadcrumbs: Administration > breadcrumbs: Board of Education > breadcrumbs: Board Policies >


Ajax Loading Image


4052a -Consent to Provide Employment History to Prospective Employees

4052 (a)






I, __________________________ (applicant), consent to any and all of my former employers to provide information regarding my employment to any prospective employer(s) who contact them.


I consent to the disclosure of the following information about me by any and all of my former employers:


  1. Date and duration of employment;
  2. Pay rate and wage history;
  3. Job description and duties;
  4. The most recent written performance evaluation provided to me during the course of my employment;
  5. Attendance information;
  6. Results of drug or alcohol tests administered within one year prior to the request for information;
  7. Threats of violence, harassing acts, or threatening behavior related to the workplace or directed at another employee;
  8. Whether I was voluntarily or involuntarily separated from employment and the reasons for the separation; and
  9. Whether I am eligible for rehire.




The consent is valid for six months from the date of my signature below.




________________________     ________________________     ______________

Printed Name                            Signature                                  Date

Back To Top