Employee Affidavit Form

EMPLOYEE AFFIDAVIT FORM

Employee Information

Employee Name:

Position Information

Anticipated Start Date:   Salary/Rate:

Affidavit — Statement of Truth

I, the undersigned employee, Employee Name: , being duly sworn, depose and state the following under penalty of perjury:

1. I certify that the information provided in this affidavit and in any accompanying employment records submitted to Employer Name: is true, accurate, and complete to the best of my knowledge.

2. I understand that knowingly making false statements in this affidavit may subject me to disciplinary action, up to and including termination of employment, and may expose me to civil and criminal penalties.

3. I attest that I have disclosed all employment history, academic credentials, and relevant legal matters as requested in this form and authorize verification of such information.

Employment History

Most Recent Employer

Dates Employed: From To

Prior Employer

Dates Employed: From To

Education

Graduation Date:

Professional References

Reference 1

Reference 2

Reference 3

Legal Disclosures and Authorizations

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

Equal Opportunity Statement: The employer affirms that employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other protected characteristic under applicable law.

Authorization to Verify and Release Information: I authorize the employer, its agents and representatives, to contact prior employers, educational institutions, licensing boards, and references provided in this form, and to obtain consumer and/or investigative background reports, criminal record checks, motor vehicle records, and other verifications as necessary for the purpose of evaluating my application or continued employment.

  I consent to release records and request that such background and reference checks be conducted in connection with my employment.

Applicant Certification

I certify that all information provided on this form and in any accompanying documents is true, correct and complete. I understand that any omission, falsification, or misrepresentation may disqualify me from employment or may result in disciplinary action, up to and including termination, even if discovered after hire.

I DECLARE under penalty of perjury under the laws of the State: that the foregoing is true and correct.

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