I request __________________________ to serve as a reference for me for the purpose of obtaining employment.

The reference may be given in the following form(s):

(check one or both spaces)

_______written

________oral

I authorize the above person to release information and provide an evaluation about any and all aspects of my job performance at the University of Minnesota to:

________all prospective employers

________specific employers (list below)

This authorization to provide references is valid for one (1) year from the date of my signature below, unless I specify an earlier ending date as follows:

Ending date:_______________________________

Employee name (please print):_____________________________________________