I, ___________________________________________, hereby authorize and request
(print name)
Middlebury College to provide any and all information regarding my employment to
_____________________________________.
In consideration of your honoring my request, I agree to release from liability Middlebury College, its directors, officers, employees and agents, and all persons from, and hold it harmless against, any and all claims of whatever nature that I might have now or in the future as a result of the College providing such information.
Social Security Number: _________________________________
Date: _____________________
___________________________________________________________
(Signature)