Employee Certifications

EMPLOYEE CERTIFICATIONS

Personal Information

Position Information

Proposed Start Date:   Annual Salary/Rate: $

Employment History (Most Recent First)

Education

Major/Field:    Graduation Date:

References (Professional)

Legal Disclosures and Acknowledgements

At-Will Employment: I understand and acknowledge 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 prior notice. This at-will relationship may not be modified except in writing signed by an authorized representative.

Equal Opportunity: I acknowledge that the employer provides equal employment opportunity to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable law.

Criminal Convictions: Have you ever been convicted of a felony? Check the box to indicate a positive disclosure and provide an explanation below. A conviction is not an automatic bar to employment; factors such as the nature of the offense, the date, and relevance to the position will be considered.
Conviction Disclosure — I certify that the following is accurate
Yes, I have a conviction to disclose    No convictions to disclose

Certifications and Authorizations

Applicant Certification: I certify that all information I have provided on this form and in any accompanying documents is true, complete and correct to the best of my knowledge. I understand that any misrepresentation or omission of material fact may result in denial of employment or, if employed, disciplinary action up to and including termination.

Authorization to Verify: I authorize the employer and its agents to investigate and verify all statements contained in this document, and to contact prior employers, educational institutions, references and any other persons or entities for the purpose of obtaining information relevant to my application and employment. I release from liability all persons and organizations for providing such information and authorize the release of personnel records as permitted by law.

Background Checks and Tests: I consent to any background, credit, criminal, drug, motor vehicle or other job-related checks that are required for my employment, subject to applicable law. I understand that my continued employment may be contingent upon satisfactory results of such checks and tests.

Applicant Certification Statement

I acknowledge that by signing below I attest under penalty of perjury that the foregoing statements are true and correct. I understand that submission of false information or failure to disclose material facts may be grounds for rejection of my application or dismissal if discovered after hire. I further understand that this form becomes part of my personnel file if I am employed.

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