Please indicate whether information was requested by telephone: No or Yes / Date
I understand the information in my workers’ compensation file(s) is confidential under Article 8307, paragraph 9a, Revised Civil Statutes of Texas. However, I do hereby waive any such right of confidentiality and both authorize the request that such information be made available to (your company name) whose address is (your company’s registered address) to whom I have made an application for employment.
Print or type name:
Social Security Number:
Date of application for employment :
State of Texas
Sworn and subscribed to before me this (day) day of (month), 19(year)
Signature of Notary Public:
Printed Name of Notary Public and seal:
My commission expires:
This information is requested in accordance with the provisions of Article 8307, para 9a, Revised Civil Statutes of Texas, as amended.
Name of Requester:
Title of Requester: