Employee Religious Exemption Form

Employee Religious Exemption Form

This form is to request an exemption from a workplace requirement on the basis of a sincerely held religious belief, practice, or observance. Complete the sections below fully and sign the certification at the end. Submission of this form authorizes the employer to review relevant information to assess the request. The employer will evaluate requests in good faith in accordance with applicable law. Providing false or misleading information may be grounds for disciplinary action.

Personal Information

Position Information

Employment Status: Full-time Part-time Contractor

Employment Start Date:

Requested Exemption

I request an exemption from the following workplace requirement(s):

Immunization/Vaccine requirement
Face covering or mask requirement
Mandatory testing requirement
Dress or grooming requirement
Specific work assignment or duty
Other:

Religious Belief, Practice, or Observance

State the specific religious belief, practice, or observance that conflicts with the identified requirement and explain how it conflicts. Include when the belief was adopted and the centrality of the belief to your religion or conscience:

Is this belief sincerely held? Yes No If no, explain:

Prior Accommodation History

Have you previously requested or received an accommodation for this or a similar belief?

Yes No

Proposed Accommodation and Impact

Can you perform the essential functions of your position with the requested accommodation?

Yes No

Supporting Documentation

Attach or list any supporting documentation that substantiates your request:

Letter or statement from religious leader or organization
Personal affidavit or sworn statement
Doctrinal or doctrinal text citations
Other supporting documents

Employment History

Former Employer 1

Former Employer 2

Education

Professional References

Reference 1

Reference 2

Reference 3

Authorizations and Disclosures

By signing below, I authorize the employer to investigate and verify the statements made in this form, including contacting present and former employers, references, and representatives of religious organizations as necessary to evaluate this request. I further authorize release of any information necessary to corroborate my statements.

I authorize the employer to contact references and prior employers

I authorize background checks or other verifications if required to evaluate the request

Legal Notices

At-Will Employment: Nothing in this form alters the at-will employment relationship, unless a separate written agreement signed by authorized management provides otherwise.

Equal Opportunity and Non-Retaliation: The employer prohibits retaliation for making a good faith request for an accommodation. Requests will be evaluated in a nondiscriminatory manner consistent with applicable law.

Burden and Undue Hardship: The employer will attempt to provide a reasonable accommodation unless doing so would impose an undue hardship on the operation of the business or create a direct threat to health or safety that cannot be mitigated by reasonable measures.

Applicant Certification

I certify that the information provided in this form and any attached documents is true, accurate, and complete to the best of my knowledge. I understand that knowingly making a false statement may subject me to disciplinary action up to and including termination.

I certify that the foregoing statements are true and complete

Acknowledgment of Review Process

I understand that submission of this form initiates an internal review. The employer may request additional information, propose alternative accommodations, or deny the request if a reasonable accommodation cannot be provided. I acknowledge that I will be informed of the decision in writing or by other recorded means.

Signature

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