III. WASHINGTON STATE EMPLOYMENT SECURITY



RELEASE OF INFORMATION AND RECORDSI, ________________________________________________, hereby authorize and request the following:EMPLOYERSEmployers are authorized and requested to share information with TRAC Associates staff regarding my employment, including such items as start date, wages, and issues that are impacting or have impacted my continued employment or ability to progress to a higher wage or position.II.TRAINING/EDUCATIONAL INSTITUTESTraining/educational institutions are requested and authorized to share information with TRAC Associates staff regarding my participation/progress in school, student ID numbers, financial aid status, and certifications.III. WASHINGTON STATE EMPLOYMENT SECURITYEmployment Security is requested and authorized to release information to TRAC Associates staff regarding employment, Unemployment Insurance claim history, and wage history. I also authorize Employment Security to share information in WorkSourceWA with TRAC Associates staff.IV. DEPARTMENT OF SOCIAL AND HEALTH SERVICESI consent to the use of confidential information about me within DSHS to plan, provide, and coordinate services, treatment, payments, and benefits for me or for other purposes authorized by law. I further grant permission to DSHS and TRAC Associates to use my confidential information and disclose it to each other for these purposes. Information may be shared verbally or by computer data transfer, mail, or hand delivery.I understand that upon receipt of this information by TRAC Associates, it will be held in the strictest of confidence and will not be released without my written permission to anyone except funding sources for the program. This authorization shall be in effect for three (3) years from the date of signature.Any copy of this document will be considered as valid as the originalSignature: ______________________________________________________Social Security Number: __________________________________________Date: __________________________________________________________ ................
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