PLEASE, JUST SIGN AND DATE BOTTON OF THIS FORM Do not

PLEASE, JUST SIGN AND DATE BOTTON OF THIS FORM
Do not complete anything else on the form.
Please take a moment to complete this reference form and fax to the Human Resource Department of
the Boys & Girls Club at (352) 621-4679 Thank you for your immediate attention to this matter.
has applied for a position within our organization and
(Name)
listed your company
as a reference.
(Company name)
Social Security Number:
Dates Employed: From:
To:
Position Held:
Eligible for Re-hire:
Reason for leaving:
Quality of Work:
Additional Comments:
Completed By:
Date:
(Signature)
Print Name:
Title:
Authorization for Release of Information
In connection with my job application to the Boys & Girls Clubs of Citrus County, I hereby authorize
Boys & Girls Clubs of Citrus County to solicit all relevant information with regards to my
employment. The authorization for release includes, but is not limited to, matters of opinion relating
to my character, ability, reputation and past conduct. I authorize and request all persons, employers,
schools, companies, corporations, credit and law enforcement agencies to release such information. I
voluntarily waive all recourse and release from any and all liability.
Signature
Date
Rev. 6/19/08