To:
From:
UMD Applicant
UMD HR Director
Re: Employment Application Release Form
As part of the final approval process of an appointment, UMD Department of Human Resources
& Equal Opportunity will conduct a reference check of previous employment as noted on your application (for the past seven years) and all degrees, licenses and certifications that you have listed on your application for employment.
You are asked to read the statement below and provide us with your Social Security Number and date of birth, so that we can complete the verification process.
While we cannot legally require you to provide your Social Security Number, be advised that without it, we may not be able to complete the verification process which is a requirement for employment.
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To whom it may concern:
I authorize the University of Minnesota Duluth to investigate employment history for the past seven years, my education history, and my references. I also authorize any persons, companies, corporations, and/or educational facilities with whom I have been associated to furnish the
University of Minnesota with any information concerning my employment and educational background which they may have on record.
To the best of my knowledge, the information included in my application materials is accurate and true. I understand that misrepresentation or omission of facts in connection with my application may be sufficient cause, in and of itself, for dismissal whenever discovered.
For degree, license, and/or certification verification purposes, provide the following information:
Other names degree may be listed under: _________________________________________
Social Security # : _______________________ Date of Birth: _________
Printed Name of applicant: ________________________________________
Signature: _____________________________ Today’s Date:__________
Department of Human Resources and Equal Opportunity
255Darland Administration Building
1049 University Drive
Duluth, Minnesota 55812-2403
Office: 218-726-7161
Fax: 218-726-7505 http://www.d.umn.edu/umdhr