Employee Verification Set

Employee Verification Set

Personal Information

Position Information

Proposed or Actual Start Date:   Salary or Rate: $

Employment History (Most Recent First)

Education

References (Professional)

Applicant Authorization and Release

I, , authorize current and former employers, educational institutions, licensing bodies, consumer reporting agencies, and references to provide employment, education, credentialing, disciplinary, or other information requested by the prospective employer or its agents. I understand that such information may include dates of employment, positions held, salary history, performance evaluations, disciplinary actions, eligibility for rehire, and reasons for separation.

Last 4 digits of Social Security Number (for identification only):   Date of Birth:

I release and hold harmless any individuals and organizations that provide information in good faith pursuant to this authorization. I waive any claim against such parties arising from disclosure of information, except for disclosures made with malice or willful misconduct. I understand that false statements or omissions may constitute grounds for withdrawal of an offer or termination of employment.

Employer Verification (To be completed by employer representative)

Employer completing this section: please provide factual responses only. This section is for verification purposes and will be retained in personnel records.

Eligible for Rehire?   Yes    No

Legal Disclosures

At-Will Employment: Nothing in this verification or any related communication is intended to constitute a promise of employment for any specified period. If employed, the employment relationship is at-will and may be terminated by either party at any time, with or without cause or prior notice, unless expressly stated otherwise in a separate written agreement signed by an authorized company representative.

Equal Employment Opportunity: The prospective employer is an equal opportunity employer. Decisions regarding hiring, promotion, compensation, and other terms and conditions of employment are made without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status, sexual orientation, gender identity, or any other characteristic protected by applicable law.

Applicant Certification and Consent

I certify that all information provided in this Employee Verification Set is true, complete, and correct to the best of my knowledge. I understand that misrepresentation or omission of material facts may disqualify me from consideration or result in termination if employed.

Authorization for Employment & Background Checks: I authorize investigation of all statements contained herein and authorize release of information by former employers, educational institutions, licensing agencies, references, and other parties. I further consent to the procurement of consumer reports, background checks, and criminal history as required for employment decisions. I understand that such checks may be conducted prior to or during employment and that I will be notified if adverse action is taken based on such reports.

Privacy and Use: Information provided and obtained pursuant to this authorization will be used solely for purposes of employment evaluation and verification and will be handled in accordance with applicable privacy and data protection laws and the employer's records retention policies.

Acknowledgement

By signing below I acknowledge that I have read and understand the terms of this Employee Verification Set and authorize disclosure of the requested information to the prospective employer or its authorized agents. I certify under penalty of perjury that the information I have provided is true and correct.

Sign Now