Employee Licence Declaration

EMPLOYEE LICENCE DECLARATION

Employer Name:    Employee Name:

Personal Information

Position Information

Reporting Manager:    Start Date:    Salary/Rate:

Employment History (Most Recent Two)

Title:    From:    To:

Title:    From:    To:

Education

Professional References

Licence / Certification Details

Issuing Authority:    Licence/Certificate Number:

Issue Date:    Expiry Date:

Is this licence required for the performance of your duties? Yes No

Have you ever had this or any professional licence suspended, revoked, restricted or subjected to disciplinary action? Yes No

Legal Disclosures and Authorizations

Representation and Warranty: I represent and warrant that the information provided in this declaration is true, complete and accurate to the best of my knowledge. I understand that misrepresentation or omission of material facts relating to licences, certifications or disciplinary history may result in disciplinary action up to and including termination of employment.

Duty to Notify: I agree to notify the employer in writing within five (5) business days of any change in the status of any licence, certification or registration required for my position, including but not limited to expiration, suspensions, revocations, limitations, renewals, or new conditions.

Authorization to Verify: I authorize the employer and its authorized agents to verify any licence, certification, registration, education, employment history and to obtain records from licensing authorities, regulatory bodies, former employers, educational institutions, and references. I further authorize the release of information necessary to verify the items identified in this form.

Authorization to Conduct Background Checks: I consent to the employer obtaining criminal, civil, regulatory and administrative records, investigative consumer reports or similar background checks as required for my role. I understand that such checks may be performed periodically during my employment where permitted by law.

Confidentiality and Use of Information: Information obtained pursuant to the foregoing authorizations will be used only for employment-related purposes and maintained in accordance with applicable privacy and record retention policies.

Indemnity: To the extent permitted by law, I agree to hold the employer harmless from any claims arising from the verification of the information provided in this declaration.

At-Will Employment & Equal Opportunity

At-Will Employment: Nothing in this declaration alters the at-will nature of employment. Employment with the employer is at-will unless expressly stated otherwise in a separate signed agreement.

Equal Employment Opportunity: The employer is an equal opportunity employer. Decisions regarding hiring, promotion, discipline and other terms and conditions of employment are made without unlawful discrimination.

Applicant Certification & Consent

I certify that all information provided on this form is true and complete. I authorize the employer to contact previous employers, licensing authorities, educational institutions and references to verify information provided. I understand that this declaration and the authorizations herein are a condition of employment where the possession of the stated licence or certification is a job requirement.

Consent to Contact Previous Employers and Background Checks: I consent to verifications of my employment record. I consent to background checks as described above.

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