I hereby authorize Interstate Background Research, Inc.
acting as an agent for __________________________________________ to receive copies of any
and/or all, or any part(s) of compensation file(s) pertaining to me. I am aware that this
request and authorization will include the release of information on all cases including
all closed, all active, and all pending cases, involving any and/or all work related
injuries, that may be on file. I have been given a conditional job offer prior to my
having completed this release request.
This Release is valid for a period of one (1) year from the date hereon.
Part A: To be completed by EMPLOYER:
Signature of Requestor: ________________________________ ** SIGN HERE
Name and Title of Requestor: ______________________________________
Company Full Name: ______________________________________
Employer Street Address: ______________________________________
Employer City, State and Zip: ______________________________________
PART B: To be completed by EMPLOYEE:
Employee Social Security Number: _______-_____-________
*Employee Date of Birth: ____/____/_______ *Gender: ________
Employee Full Name: ______________________________________
Employee Street Address: ______________________________________
Employee City, State and Zip: ______________________________________
Date of this request: ___/___/______
Signature of Employee: _______________________________ ** SIGN HERE
THANK YOU
* May be deemed necessary to conduct a thorough criminal record search in accordance with the, "Code of Federal Regulations" Equal Employment Opportunity Commission Code 1625.5.
Subscribed and sworn in my presence this _______ day of ____________
in the year of ____ ____ , a Notary Public in and for the State of _____________ .
_______________________________________ (NOTARY sign and SEAL here)
My commission expires ___ ___ of __________ in the year of ____ ____ .
PLEASE MAIL of FAX to: IBRInc
Post Office Box 817
New Port Richey, Florida
34656-0817
FAX (727) 848-7340
form comp_rel rev 11/23/1998