I hereby authorize ChoicePoint acting as an agent for ___________________________________________ to review and/or receive copies of any or all parts of compensation claim files(s). I understand this authorization will include release of information covering both pending and closed cases involving any work related injuries on file. I have been given a conditional job offer prior to my completion of this release.

To be completed by EMPLOYER:

Date of request:___________________________________________

Signature of requester:___________________________________________

Employer's Full Name:___________________________________________

Employer's Street Address:___________________________________________

Employer's City, State and Zip Code:___________________________________________

To be completed by EMPLOYEE:

Employee's Social Security Number:___________________________________________

Employee's Date of Birth:___________________________________________

Employee's Full Name:___________________________________________

Employee's Street Address:___________________________________________

Employee's City, State and Zip Code:___________________________________________

Signature of Employee:___________________________________________




Subscribed and sworn before me, in my presence, this ________ day of ____________________

19, ____, a Notary Public in and for the state of ______________________________________.


						     _______________________________________
						     (Signature of Notary Public)

My Notary Commission expires ________________, 19_____.


Note: This information is not to be used in a manner which would violate the Americans with Disabilities Act.


ChoicePoint Form-WC4

Revised 04/22/05








  

    

      
    
    

    

    

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