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General Release of Information

I hereby give my permission to CareerSource Citrus Levy Marion staff to obtain and/or disclose my past, present, and future information or records that may be needed for eligibility determination, monitoring, and follow-up purposes. This information may include, but shall not be limited to employment information, assistance records, and assessment or evaluation tools. A photocopy/facsimile of this signed consent form may be used to obtain/release information authorized by signature on this form. It is also my understanding that any information obtained by the above organization will be held in strict confidence. Providing the information is voluntary. The information will be kept confidential as provided by law. Refusal to provide the information will not subject you to any adverse treatment. The information will be used only in accordance with the law. I understand that I may revoke this consent at any time by providing a written statement to staff indicating that my consent to the release of information is no longer given to the party(ies) previously granted permission.

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