ࡱ> 685 bjbj ;$gg %""8$$Ut@@"bbb===$"J==JJbb```JFbb`J```b@ hv`%0U`-#-#`-#``=vT`DK===p===UJJJJ-#========="X z:  AUTHORIZATION FOR REFERENCE CHECKS In order to further my evaluation as a candidate for employment with the Office of the Chancellor of Colleges and Universities, I hereby authorize all individuals I have listed as references, and others who have knowledge about my qualifications for employment, to provide information about any and all aspects of my work performance or job-related qualifications as requested by authorized representatives of Colleges and Universities. I understand that some of the information that Colleges and Universities may request may be classified by law as private and cannot be disclosed without my written consent. This authorization permits written and oral disclosure of information about my professional and personal work-related qualifications, even if it is classified as private. The information obtained will be used by Colleges and Universities to evaluate my qualifications for employment. Unless limited below, this authorization includes individuals who have knowledge of my qualifications regardless of whether I have listed them as references. Note: This form does not authorize the disclosure of medical information or college/university transcripts, which may be authorized by separate procedure, where applicable. This authorization specifically includes, but is not limited to, disclosure (including copies if requested) of information that may be contained in the following (check if applicable): ___ Written evaluations conducted before separation from employment; ___ My written response(s) to evaluations contained in my personnel record; ___ Written reasons for separation from employment. Please list any limitations in the authorization (for example, information not to be released, or individuals you request not be contacted, including current employer) but do not include reasons: ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Continued) Optional: If desired, a brief explanation of any limitations listed above may be supplied separately to the Chair of your search committee. This authorization is valid for one year from the date below or until the purpose has been fulfilled, whichever occurs first. This authorization may be withdrawn by notifying the Chair of the search committee or Human Resources Office in writing, but such withdrawal does not affect the validity of disclosures made prior to the withdrawal notice. I understand that I am not legally required to sign this authorization, but if I do not do so, may be unable to adequately evaluate my qualifications for employment. 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