LAST NAME                                        FIRST NAME

SOCIAL SECURITY #

Please list two work references.
Company Name			Company Name
Attention			Attention
Address			Address
City	State	Zip	City	State	Zip
Phone			Phone

CAREFULLY READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW      I authorize you to release to Exceptional Persons, Inc. the information relevant to my work performance.      I UNDERSTAND by entering today's date and my name I will be electronically signing my reference authorization. Today’s Date   /   /   Signature