TO: [School District]

RE: Personnel Records of [name]

(Date of Birth and/or Social Security Number)

This is your full and sufficient authorization, pursuant to Minn. Stat. § 13.05, Subd. 4 and Minn. 

Rules 1205.1400, Subp. 4, to release to , their 

representatives or employees, all information pertaining to [describe] 

maintained by the employer school district, with the following exceptions: 

The information is needed for the purpose of [specify] 

This authorization specifically includes records prepared prior to the date of this authorization and records prepared after the date of this authorization, such records to be used only for the purpose specified.  I do not authorize re-release of this information by the third party.

I understand that I may revoke this consent in writing at any time.  Upon the fulfillment of the above-stated purpose, this consent will automatically expire without my express revocation.  A photocopy of this authorization will be treated in the same manner as an original.


Signature of Employee

ATTENTION PUBLIC FACILITIES:  Minn. Stat. § 13.05 requires automatic expiration of this authorization one (1) year from the date of authorization.