Form 1826 "Release of Information Authorization" - Oregon

What Is Form 1826?

This is a legal form that was released by the Oregon Employment Department - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2015;
  • The latest edition provided by the Oregon Employment Department;
  • Easy to use and ready to print;
  • Available in Vietnamese;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 1826 by clicking the link below or browse more documents and templates provided by the Oregon Employment Department.

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Download Form 1826 "Release of Information Authorization" - Oregon

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RELEASE OF INFORMATION AUTHORIZATION
MUST BE WITNESSED OR NOTARIZED
Name:
Social Security Number:
For identification purposes only
I authorize the State of Oregon Employment Department, to release the following information from my records
(Please initial those that apply)
____ Name, address, telephone number and demographic information
____ Services that I have received or will receive
____ Work history and other information that I provided for job placement purposes
____ Wage record information
____ Unemployment insurance information (i.e. ECLM and/or Wage & Benefit report, etc.)
____ TAA services information (i.e., training, job search & relocation) and/or TRA unemployment insurance information
____ Other (must be specifically identified below)
I am authorizing the release of this information to the following individual or organization:
The purpose for the release:
I understand that information obtained under the release will only be used for the above purpose or purposes.
I understand this authorization will be in effect until canceled in writing by me (for placement information) or
for the duration of my unemployment insurance claim (for UI information).
I understand that information in my records is confidential and that I approve the release of the information listed above.
I understand that state government files will be accessed to obtain the information.
Releasing this information to this party will provide a service to me or benefit me.
I understand the purpose of this authorization.
I am signing on my own and have not been pressured to do so.
Signature:
Date:
NOTE: Redisclosure of any information received is strictly prohibited
WorkSource Oregon is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Language assistance is available to person with
limited English proficiency at no cost.
WorkSource Oregon es un programa/empleador que respeta la igualdad de oportunidades. Ayudas auxiliares y servicios para personas con discapacidades estará disponible sin costo. Asistencia de
idiomas para personas con conocimiento limitado del inglés sin costo alguno.
EMPLOYMENT DEPARTMENT
ONE-STOP PARTNER*
If witnessed by Employment Department staff the portion below must be
If witnessed by a one-stop partner* the portion below must be
completed.
completed. Partners should retain this document and submit it to the
Employment Department with any/each request for information.
Printed name of witness: _______________________________________
Partner organization: _________________________________________
Signature of witness: __________________________________________
Printed name of witness: ______________________________________
Field Office: _________________________________________________
NOTARY
Signature of witness: _________________________________________
If notarized the following must be completed:
Telephone number of witness : _________________________________
State of: _______________________ County: _____________________
*Authorized partner staff must have signed the Employment
Signature (of notary): __________________________________________
Department’s Commitment to Confidentiality
Commission expires:
State of Oregon Employment Department • www.Employment.Oregon.gov
Form 1826 (0815)
RELEASE OF INFORMATION AUTHORIZATION
MUST BE WITNESSED OR NOTARIZED
Name:
Social Security Number:
For identification purposes only
I authorize the State of Oregon Employment Department, to release the following information from my records
(Please initial those that apply)
____ Name, address, telephone number and demographic information
____ Services that I have received or will receive
____ Work history and other information that I provided for job placement purposes
____ Wage record information
____ Unemployment insurance information (i.e. ECLM and/or Wage & Benefit report, etc.)
____ TAA services information (i.e., training, job search & relocation) and/or TRA unemployment insurance information
____ Other (must be specifically identified below)
I am authorizing the release of this information to the following individual or organization:
The purpose for the release:
I understand that information obtained under the release will only be used for the above purpose or purposes.
I understand this authorization will be in effect until canceled in writing by me (for placement information) or
for the duration of my unemployment insurance claim (for UI information).
I understand that information in my records is confidential and that I approve the release of the information listed above.
I understand that state government files will be accessed to obtain the information.
Releasing this information to this party will provide a service to me or benefit me.
I understand the purpose of this authorization.
I am signing on my own and have not been pressured to do so.
Signature:
Date:
NOTE: Redisclosure of any information received is strictly prohibited
WorkSource Oregon is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Language assistance is available to person with
limited English proficiency at no cost.
WorkSource Oregon es un programa/empleador que respeta la igualdad de oportunidades. Ayudas auxiliares y servicios para personas con discapacidades estará disponible sin costo. Asistencia de
idiomas para personas con conocimiento limitado del inglés sin costo alguno.
EMPLOYMENT DEPARTMENT
ONE-STOP PARTNER*
If witnessed by Employment Department staff the portion below must be
If witnessed by a one-stop partner* the portion below must be
completed.
completed. Partners should retain this document and submit it to the
Employment Department with any/each request for information.
Printed name of witness: _______________________________________
Partner organization: _________________________________________
Signature of witness: __________________________________________
Printed name of witness: ______________________________________
Field Office: _________________________________________________
NOTARY
Signature of witness: _________________________________________
If notarized the following must be completed:
Telephone number of witness : _________________________________
State of: _______________________ County: _____________________
*Authorized partner staff must have signed the Employment
Signature (of notary): __________________________________________
Department’s Commitment to Confidentiality
Commission expires:
State of Oregon Employment Department • www.Employment.Oregon.gov
Form 1826 (0815)