Employee License Application

EMPLOYEE LICENSE APPLICATION

Administrative Information

Personal Information

Full Legal Name:

Date of Birth:

Phone:    Email:

Employee ID:    Hire Date:

Position Information

Department:    Reporting Manager:

License Details

Issuing Authority:    License/Cert. Number (if held):

Current Expiration Date:

Employment History (Most Recent First)

Title:    Dates Employed From:    To:

Title:    Dates Employed From:    To:

Education

Institution:    Graduation Date:

Professional References

Phone:    Email:

Phone:    Email:

Phone:    Email:

Attachments & Financial Assistance

Please indicate documents attached:

Copy of current license/certificate

Transcripts or training records

Application fee receipt

Request for Employer Reimbursement or Sponsorship: Yes No

Legal Disclosures, Authorizations, and Representations

At-Will Employment: I understand that submission of this application does not alter the at-will employment relationship and that nothing in this application confers a contract of employment or continued employment for any specific duration.

Equal Employment Opportunity: The employer provides equal opportunity in employment and licensing support without regard to race, color, religion, sex, national origin, age, disability, or legally protected status.

Authorization to Verify: I authorize the employer and its designated agents to obtain and verify information concerning my employment history, education, professional licenses and certifications, and any other information reasonably related to this application. I further authorize third parties to release such information upon request.

Background and License History: I certify that I have not had a professional license revoked, suspended, disciplined, or otherwise restricted except as disclosed below. I understand the employer may conduct criminal history checks and licensing board inquiries where permitted by law.

Yes No

Certification Regarding Truthfulness: I certify under penalty of law that the statements made in this application and any attachments are true, complete, and correct to the best of my knowledge. I understand that falsification or omission of information may result in denial of the application, disciplinary action, or termination.

Ongoing Obligation: If a license is granted or supported by the employer, I agree to maintain the license in good standing, to timely complete required renewals and continuing education, and to promptly notify Human Resources of any change in status, discipline, or lapse.

Applicant Certification

I certify that all information provided in this Employee License Application and all attached documents is true and complete. I authorize the employer to verify any information provided and to obtain reports as necessary to evaluate this application. I understand that approval of this application is contingent upon verification of information and applicable employer policies governing licensure, reimbursement, and use of employer funds.

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