I,                                                                      , hereby request that the Payroll Department of Bryn Mawr College (“the College”) provide the information listed below to the person/entity listed below, in the manner specified:


Information to be released by the College:


__ Duplicate W2 year ___________


__ Payroll History


__ Other, please describe




Person/Entity to whom I request information be provided:




Contact method for information to be released (please check one):


__ U.S. Mail __ Facsimile Transmission __ E-mail


Contact information (address, fax number, e-mail address to which I request the above-listed information be transmitted):






In consideration of the provision of information by the College’s Payroll Department to the above-named person/entity at my request, I do release from any liability and agree not to sue Bryn Mawr College, its governing board, officers, agents, employees, and any students acting as employees (“Releasees”), for any harm and expenses of any nature which I may have or which may hereafter accrue to me, arising out of or related to any loss, or injury that may be sustained by me due to the College’s provision of this information.





Signature                                                                              Date


                                    (Last four digits of social security number)