Employee Access Acknowledgement

EMPLOYEE ACCESS ACKNOWLEDGEMENT

Personal Information

Position Information

Employment History (Most Recent First)

Education

Professional References

Access Request — Systems and Resources

The employee requests access to the following systems and resources. Select each requested item and indicate the desired level of access. The employer retains sole discretion to grant, modify, or revoke access.

Email / Corporate Mailbox — Access Level:

VPN / Remote Access — Access Level:

HRIS / Employee Records — Access Level:

Payroll / Finance Systems — Access Level:

Source Code Repository — Access Level:

Production Environment / Admin Console — Access Level:

Physical Building / Badge Access — Area(s):

Other — Describe and Access Level:

Security, Confidentiality, and Policy Acknowledgements

By signing below the employee affirms understanding of and agreement to the following conditions. Failure to comply may result in disciplinary action, revocation of access, civil liability, or criminal prosecution where applicable.

I acknowledge and will comply with the company's Acceptable Use and Information Security policies, including restrictions on unauthorized access, sharing of credentials, and use of company systems for personal commercial activities.

I will protect confidential and personally identifiable information in accordance with applicable policy and will not remove or disclose confidential data except as authorized.

I will use multifactor authentication where required, create strong passwords, and will not share passwords or authentication tokens.

I will maintain required endpoint security on devices used to access company systems and will promptly report lost or compromised devices.

I understand that employer systems and communications may be monitored and audited, including access logs, and I have no expectation of privacy while using company resources.

Access privileges remain the property of the employer. Upon separation of employment or upon request, I will return badges, devices, and other credentials and will immediately cease use of privileged accounts. I further acknowledge that unauthorized retention or disclosure of confidential information may subject me to disciplinary action, termination, and legal proceedings.

Legal Disclosures and Authorizations

At-Will Employment Statement: I understand that, unless otherwise specified in a separate written agreement signed by an authorized representative of the employer, employment is at-will and may be terminated by either party at any time, with or without cause.

Equal Opportunity: The employer provides equal employment opportunity in accordance with applicable law and does not discriminate on the basis of protected characteristics.

Authorization: I authorize the employer and its agents to verify the information provided in this form and to contact prior employers and references. I also authorize background checks, credit checks where job-related and permitted by law, and any other pre-employment or continuing employment screening required by company policy or applicable law.

I authorize employment verification, reference checks, and background screening as described above.

Applicant Certification

I certify that all information provided on this form is true and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may disqualify me from access privileges, subject me to disciplinary action, or be grounds for termination.

Manager / Administrator Information

Sign Now