Employee Client Consent Form

EMPLOYEE CLIENT CONSENT FORM

PERSONAL INFORMATION

POSITION / ASSIGNMENT INFORMATION

Reporting Manager:

Client Company:

EMPLOYMENT HISTORY

Employer 1

Employer 2

EDUCATION

Graduation Date:

REFERENCES

Reference 1 — Name: Phone: Email:

Relationship:

Reference 2 — Name: Phone: Email:

Relationship:

Reference 3 — Name: Phone: Email:

Relationship:

LEGAL DISCLOSURES & CONSENTS

By signing below I authorize Employer and the Client named above to collect, maintain, and use personal information about me that is necessary for assignment, billing, site access, regulatory compliance, and health & safety. Client Company: .

I authorize my current and former employers, educational institutions, licensing authorities, and references to release to Employer and Client any and all information regarding my employment history, performance, disciplinary records, licensure, certifications, and educational credentials. I hereby release such parties from liability for providing such information in good faith.

I consent to criminal background checks, drug and alcohol screening, verification of professional licenses and certifications, and other pre-assignment checks required by the Client or applicable law. I understand that the results of such checks may affect my eligibility for assignment and that refusal to consent may result in non-placement.

I consent to the disclosure to the Client of personal data reasonably necessary to perform the assignment, including but not limited to identity information, qualifications, emergency contact details, and health and immunization information where required for site access or safety compliance. I understand that such disclosures are limited to the purposes set forth above.

While working on Client premises, I agree to comply with Client policies and site-specific safety and security rules. I understand that failure to comply with Client policies may result in removal from the site or termination of assignment.

I acknowledge that Employer is an independent organization providing staffing services and that Client has the authority to direct my day-to-day activities while on assignment. I understand that Employer and Client may require confidentiality agreements for access to proprietary or confidential information and that unauthorized disclosure may result in disciplinary measures.

I authorize Employer and Client to obtain consumer and/or investigative consumer reports for employment-related purposes, including pre-placement and ongoing monitoring to the extent permitted by law. I understand I may be required to complete separate consent forms for certain types of checks where required by law.

APPLICANT CERTIFICATION & AUTHORIZATION

I certify that all information I have provided on this form and in any accompanying documentation is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation or omission may result in denial of assignment, removal from Client site, or termination of employment with Employer.

I expressly authorize Employer and Client to contact the references and prior employers listed on this form and to obtain any records or information necessary to evaluate my qualifications and suitability for assignment. I release Employer, Client, and the persons and entities providing information from any liability arising from the disclosure or use of such information.

EMPLOYMENT POLICIES

At-Will Employment: I understand that, unless otherwise provided in a separate written agreement signed by an authorized representative of Employer, my assignment and employment are at-will. Either I or Employer may terminate the assignment or employment relationship at any time, with or without cause or notice.

Equal Opportunity: Employer is an equal opportunity provider. Decisions regarding employment and assignment are made without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other protected characteristic under applicable law.

ACKNOWLEDGEMENT OF RECEIPT

By signing below I acknowledge that I have read and understand this Employee Client Consent Form, that I have had an opportunity to ask questions, and that I voluntarily provide the consents and authorizations contained herein.

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