Free Employment Records Authorization - Kansas

EMPLOYMENT RECORDS AUTHORIZATION
TO:

The undersigned hereby authorizes you to forward to the law firm of ________________ ______________________________________________________________________________ ______________________________________________________________________________ any and all records, reports, or other information, to include wage verification, which they request, concerning my employment with you, at the latter's request and expense. The undersigned further states that photostatic copies of this authorization shall have the full force and effect of the original. Dated this _________ day of ______________________, 20______. ___________________________________ SIGNATURE Social Security No. _____ - ____ - ______ Date of Birth ____/_____/_____ STATE OF _________________________ ) ) ss: COUNTY OF ________________________ ) On this ______ day of ____________________, 20_____, before me, a Notary Public in and for the county and state aforesaid, appeared _______________________________, personally known to me to be the same person who executed the above instrument and duly acknowledged the execution of the same. IN WITNESS WHEREOF, I have hereunto set my hand and seal on the date last above written. ____________________________________ Notary Public My Appointment Expires: __________________________
Revised: 5-19-99