Employee Declarations Form

EMPLOYEE DECLARATIONS FORM

Personal Information

Position Information

Employment History (Most recent first)

Education

References (Professional)

Legal Disclosures and Acknowledgements

At-Will Employment: I acknowledge that, unless otherwise expressly agreed in a separate written contract 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.

Equal Opportunity: I understand the employer provides equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or other protected classifications as required by law.

Decla­rations (Respond to each item and provide details where requested)

1. Conflicts of Interest: I have disclosed any financial or personal interests that could reasonably be expected to create a conflict of interest with the employer's business. Yes No

2. Outside Employment / Business Interests: I currently hold outside employment or operate a business that could interfere with my duties. Yes No

3. Non-Competition / Restrictive Agreements: I am bound by any non-compete, non-solicitation, confidentiality, or other restrictive covenant from prior employment. Yes No

4. Termination for Cause: I have ever been terminated, resigned in lieu of termination, or subject to disciplinary separation from any prior employer. Yes No

5. Criminal Convictions: Have you been convicted of a crime that has not been annulled, expunged, or sealed by a court? Convictions that are job-related may be considered in hiring decisions. Yes No

6. Work Authorization: I am legally authorized to work in this country and can provide documentation to verify identity and employment authorization upon request. Yes No

7. Professional Licenses / Certifications: I hold licenses or certifications relevant to the position that are currently active and in good standing. Yes No

8. Driving Record: For roles requiring driving, I certify that my driving record is free of disqualifying offenses and that I possess a valid driver's license. Yes No

Authorization & Certification

Background and Reference Checks: I authorize the employer to verify all information provided in this form and in any application, to contact prior employers and references, and to obtain consumer reports, background checks, driving records, and other employment-related information as permitted by law. I understand that an offer of employment may be contingent on the results of such checks and verifications.

Certification: I certify under penalty of perjury that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that any false or misleading statements, omissions, or misrepresentations may result in denial of employment or, if employed, disciplinary action up to and including termination.

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