I acknowledge that I have been informed that it is [Your Business's] general policy to disclose in response to a prospective employer's request only the following information about current or former employees: (1) the dates of employment, (2) descriptions of the jobs performed, and (3) salary or wage rates.

By signing this release, I am voluntarily requesting that [Your Business] depart from this general policy in responding to reference requests from any prospective employer that may be considering me for employment. I authorize [Your Business] to disclose to such prospective employers any employment-related information that [Your Business], in its sole discretion and judgment, may determine is appropriate to disclose, including any personal comments, evaluations, or assessments that [Your Business] may have about my performance or behavior as an employee.

In exchange for [Your Business's] agreement to depart from its general policy and to disclose additional employment-related information pursuant to my request, I agree to release and discharge [Your Business] and [Your Business's] successors, employees, officers, and directors for all claims, liabilities, and causes of action, know or unknown, fixed or contingent, that arise from or that are in any manner connected to [Your Business's] disclosure of employment-related information to prospective employers. This release includes, but is not limited to, claims of defamation, libel, slander, negligence, or interference with contract or profession.

I acknowledge that I have carefully read and fully understand the provisions of this release. I further acknowledge that I was given the opportunity to consult with an attorney or any other individual of my choosing before signing this release and that I have decided to sign this release voluntarily and without coercion or duress by any person.

This release sets forth the entire agreement between [Your Business] and me, and I acknowledge that I have not relied upon any representation or statement, written or oral, not set forth in this document.

Signed: ________________________________________ Date: _______________

(Employee)