Reference Release Form

Please complete and submit the following form for each previous place of employment.

Name(Required)

First Last

Position(s) applying for at McHarrie Life:(Required)

Previous Employer Name(Required)

Previous Employer Address(Required)

Street Address City State ZIP Code

Start Date / End Date(Required)

Previous Position Title(Required)

During this period of employment, I was known by the name:(Required)

Please sign below:(Required)

I authorize McHarrie Life to contact my present and previous employers and schools, and unless otherwise indicated, I further authorize my former employers to give any information as to my character and work or school record, including employment dates and positions held. I hereby release from all liability, and damages, all these individuals or companies which are providing such information. I further understand that all hiring commitments are conditionally based upon satisfactorily meeting statutory standard through a job related post-offer, physical examination, and satisfying pre-employment requirements.*