Employee Verification Template

EMPLOYEE VERIFICATION TEMPLATE

Requester Information

Requester Company:

Employee Personal Information

Employee Name:

Former Names / Aliases:

Social Security Number (last 4 digits):

Position Information

Employment Start Date:    Employment End Date (if applicable):

Employment Status: Current Employee Terminated On Leave Other

Verification Requested

Please indicate the items requested for verification. The employer will complete the checked items.

Dates of Employment Position / Title Salary / Wage Reason for Separation Rehire Eligibility

Employment History (Additional Records)

Please provide prior employment records for the employee where applicable. At least two employer blocks are provided below.

Education

Graduation Date:

References (Professional)

Provide three professional references.

Legal Disclosures & Authorizations

At-Will Employment Statement: The employee's relationship with the employer is at-will unless otherwise set forth in a written employment agreement signed by an authorized representative of the employer. Nothing in this verification form alters or amends that relationship.

Equal Employment Opportunity: The employer adheres to laws prohibiting discrimination in employment on the basis of protected characteristics. This verification is provided in compliance with those obligations and consistent with company policy.

Applicant Certification: I certify that all information provided to the requester and employer in connection with this verification request is true and complete. I understand that knowingly providing false information is grounds for disciplinary action and may be penalized under applicable law.

Authorization to Release Records: I, the undersigned employee, authorize the employer to release employment information as indicated on this form to the requester named above. I authorize the release of records that may include dates of employment, job title, compensation, reason for separation, and rehire eligibility. This authorization is valid for a single disclosure to the identified requester unless otherwise specified in writing.

I authorize release of the requested employment information to the requester identified above.

Employer Verification (To be completed by Employer Representative)

The person completing this section must be authorized to release employment information and must certify that answers are derived from official personnel records.

Employer Certification: I certify that the information provided on this form is true and accurate to the best of my knowledge and is derived from official employment records maintained by the employer. I understand that intentional misrepresentation of employment information may subject the employer to liability and/or corrective measures as required by law.

Data Handling and Limitation of Liability: The requester agrees to treat verification data as confidential and to use it only for the stated purpose. The employer's liability for release of employment information is limited to willful misrepresentation; the employer shall not be liable for actions taken in good faith reliance on employee records.

Authorization to Contact Prior Employers / Background Checks

By signing below, the employee authorizes the requester and employer to contact prior employers as necessary to validate employment history and to conduct lawful background checks as permitted by applicable law. Such inquiries may include verification of dates of employment, position, compensation, disciplinary history, and rehire eligibility.

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