BILL RICHARDSON 401 Broadway, NE

 P.O. Box 1928

GOVERNOR
Albuquerque, NM 87103
(505) 841-8409
(505) 841-8491 FAX

CONROY CHINO 1596 Pacheco Street

SECRETARY  P.O. Box 418
Santa Fe, NM 87502-4218
(505) 827-6827
(505) 827-6812 FAX
STATE OF NEW MEXICO
DEPARTMENT OF LABOR

RELEASE AND WAIVER

TO: PRESENT/FORMER EMPLOYER(S)

FROM:
(Candidate’s Name)

I hereby authorize any duly accredited representative of the New Mexico Department of Labor
(Department) to obtain from you information relating to my activities as an employee. This
Release & Waiver applies to information which includes, but is not limited to, data regarding my
achievement, salary, performance, attendance and disciplinary information. This information
will be held in confidence.

This Release and Waiver replaces any prior agreement or statement I may have made with you
previously. I agree that a facsimile copy of this signed authorization shall be effective as my
original signature.

As against any person or entity supplying this information, I hereby waive any right of action,
cause of action or means of redress I may have which might arise from the person supplying the
information to the Department.

_____________________________ _____________________________
Printed Name Social Security Number

_____________________________ _____________________________
Signature Date

Appendix 1

“AN EQUAL OPPORTUNITY EMPLOYER”