Employee Background Drug Release

EMPLOYEE BACKGROUND DRUG RELEASE

Personal Information

Full Legal Name:

Phone:    Email:

Date of Birth:    Social Security Number:

Position Information

Department:    Reporting Manager:

Proposed Start Date:    Proposed Salary/Hourly Rate:

Employment History (Most Recent First)

Education

Institution:    Graduation Date:

References (Professional)

Legal Disclosures

At-Will Employment: I understand that unless otherwise provided by written agreement signed by an authorized representative of the employer, employment is at-will, which means the employer or I may terminate the employment relationship at any time, with or without cause or notice.

Equal Opportunity: The employer is an equal opportunity employer. Selection decisions are made without regard to race, color, religion, sex, national origin, age, disability, genetic information, or other protected status as required by applicable law.

Authorization & Release — Background and Drug Testing

By signing below, I authorize the employer, its agents, third-party screening services, and designated representatives to obtain consumer reports and investigative consumer reports, including criminal history, driving records, credit reports (where job-related), education verification, employment history, and other job-related information for purposes of evaluating my application for hire or continued employment. I further authorize all persons and entities that may have information about me to provide such information to the employer or its agents.

I also consent to submit to pre-employment and/or random drug and alcohol screening, and any other testing required by the employer as a condition of employment. I authorize the collection of urine, blood, hair, breath, or other specimens as required by the employer's testing procedures and consent to the release of test results to the employer and testing laboratory. I understand that a confirmed positive test may result in refusal of employment, conditional employment, or disciplinary action in accordance with employer policy and applicable law.

I hereby release and hold harmless the employer, its agents, third-party screening companies, laboratories, and all persons providing information from any and all liability arising out of the collection, use, disclosure, or receipt of such information, to the extent permitted by law. I understand that information obtained will be used only for the stated employment purposes and will be retained and disposed of in accordance with applicable law and employer policy.

I understand that I have the right to request, in writing, a copy of any consumer report obtained by the employer and that I may dispute the accuracy of any information contained therein with the reporting agency. My authorization shall remain in effect for the duration of my application and, if employed, for the term of employment unless revoked in writing.

Applicant Certification & Authorization

I certify that the information provided on this form and any attachments is true, correct, and complete to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may disqualify me from consideration for employment or, if employed, may result in disciplinary action up to and including termination.

I expressly authorize the employer to contact former employers, educational institutions, references, and other relevant sources to verify the information provided. I authorize those contacts to release to the employer any information relevant to my employment, including performance, disciplinary history, attendance, and reasons for separation.

Criminal Convictions and Related Disclosures

Have you ever been convicted of a felony? Yes No

Applicant Acknowledgements

I acknowledge receipt of this document and that I understand its contents. I understand that consent is a condition of application and, if employed, employment may be conditioned upon successful completion of background checks and drug testing required by the employer's policy and applicable law.

I further acknowledge that this authorization and release is effective and valid until revoked by me in writing, and that any revocation will not apply to disclosures or actions taken prior to receipt of such written revocation.

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