Employee Background Statement

EMPLOYEE BACKGROUND STATEMENT

This Employee Background Statement is submitted to provide a complete and accurate record of background and qualifications for employment consideration. Completion of this statement authorizes verification of the information provided and any further investigation as permitted by law.

Personal Information

Date of Birth:    Place of Birth:

Phone:    Email:

Position Information

Department:    Reporting Manager:

Available Start Date:    Desired Compensation:

Legally authorized to work in this country: Yes No

Employment History (Most Recent First)

Employer 1

Phone:    Supervisor:

Job Title:    Dates Employed: From to

Employer 2

Phone:    Supervisor:

Job Title:    Dates Employed: From to

Education

Major/Field:    Graduation Date:

Licenses, Certifications, and Professional Affiliations

Criminal and Disciplinary History

Have you ever been convicted of a felony or misdemeanor (excluding minor traffic offenses)? Yes No

Have you ever been subject to disciplinary action, suspension, or termination from any employer? Yes No

Military Service

Branch:    Rank/Rate:

Dates of Service:

References

Reference 1

Phone:    Email:

Reference 2

Phone:    Email:

Reference 3

Phone:    Email:

Authorization and Release

I hereby authorize the Company and its agents to investigate and verify all statements and information provided on this form and any accompanying documents. This authorization includes contacting prior employers, educational institutions, references, licensing authorities, and other third parties for the purpose of obtaining background information and records relevant to my application or continued employment, subject to applicable law.

I authorize the release of any records or information requested by the Company. I release from liability all persons, companies, and organizations that provide such information. I understand that any employment offer is conditional upon satisfactory completion of required background checks, which may include criminal record checks, employment verification, education verification, drug testing, and professional license verification where applicable.

I grant permission for the Company to obtain consumer and/or investigative consumer reports as permitted by law. I understand that I may be required to sign a separate disclosure and authorization for procurement of such reports where required by law.

Consent to background checks: I consent to background investigations as described above.

Equal Opportunity and At-Will Employment

The Company is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex, national origin, disability, age, genetic information, military status, or any other characteristic protected by law. The Company complies with applicable disability accommodation obligations.

Unless otherwise provided in a written agreement signed by an authorized representative of the Company, employment with the Company is at-will, which means that either the employee or the Company may terminate the employment relationship at any time, with or without cause or advance notice.

Applicant Certification

I certify that all information provided on this Employee Background Statement and any attachments is true, correct, and complete to the best of my knowledge. I understand that any omission, false statement, misrepresentation, or concealment of facts may result in rejection of my application or termination of employment if discovered at a later date.

I understand and agree that this statement will become part of my personnel file if I am employed. I acknowledge that I have read and understand the foregoing authorizations and certifications and that I have the right to refuse to consent.

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