University of Minnesota Duluth

University of Minnesota Duluth
UMD Applicant
UMD HR Director
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.
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: _____________________________
Department of Human Resources and Equal Opportunity
255Darland Administration Building
1049 University Drive
Duluth, Minnesota 55812-2403
Today’s Date:__________
Office: 218-726-7161
Fax: 218-726-7505
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