Employee Disclosure Document

EMPLOYEE DISCLOSURE DOCUMENT

Personal Information

Position Information

Proposed Start Date:

Employment History (Most Recent)

Employment History (Prior Employer)

Education

Graduation Date:

References (Professional)

Mandatory Disclosures

Have you ever been convicted of a felony or misdemeanor that has not been expunged or sealed? Yes — I have a conviction to disclose

Within the past seven years, have you been subject to disciplinary action, termination, or formal investigation by a current or former employer that is not protected by law? Yes — I have disciplinary matters to disclose

Do you currently hold any security clearance, or have you had one revoked or suspended? Yes — provide clearance details

Are you a party to any non-compete, non-solicit, confidentiality, or similar agreement that may affect your ability to perform the duties of the position? Yes — I have current restrictive covenants

Do you have any current outside employment, business interests, or financial relationships with vendors, competitors, or customers that could create a conflict of interest? Yes — disclose below

Do you or any immediate family members have a financial interest in any current or prospective vendor or contractor of the employer? Yes — disclose below

Have you filed for bankruptcy in the past seven years? Yes — provide details

Are any immediate family members employed by the employer or in a position of authority that could create a supervisory or procurement conflict? Yes — list names and relationships

Legal Statements, Authorizations and Certifications

At-Will Employment: Unless expressly set forth in a separate written employment agreement signed by an authorized representative, employment is at-will and either the employee or the employer may terminate the employment relationship at any time, with or without cause or notice. Nothing in this Disclosure Document modifies the at-will status unless a specific, written agreement states otherwise.

Equal Employment Opportunity: The employer maintains a policy of equal employment opportunity and will make employment decisions without regard to protected characteristics under applicable law. Reasonable accommodations for qualified individuals with disabilities will be considered in accordance with law.

Background Checks and References: I authorize the employer and its agents to contact my current and prior employers, educational institutions, references, and other third parties to verify the information provided and to obtain background information, including, but not limited to, employment verification, financial records, criminal records, motor vehicle records where job related, and other public record information to the extent permitted by law. I hereby release those parties from liability for providing such information.

Certification: I certify that the information contained in this Employee Disclosure Document is true, complete and correct to the best of my knowledge. I understand that false or misleading statements, omissions, or misrepresentations may result in denial of employment, revocation of an offer, or disciplinary action up to and including termination for cause. I agree to notify the employer promptly of any material change in the information provided.

Consent to Drug and Alcohol Testing: As a condition of employment and in accordance with employer policy and applicable law, I consent to drug and alcohol testing where permitted.

Applicant Authorization and Acknowledgment

By signing below, I acknowledge receipt of this Employee Disclosure Document, authorize the disclosures and verifications described above, and understand my obligations to disclose information required by this document and employer policy. I understand that this document will become part of my personnel record if hired.

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