Employee Worker Accreditation Form

EMPLOYEE WORKER ACCREDITATION FORM

Purpose: This form documents the identification, credentials, employment history, qualifications and authorizations required to accredit an individual as an authorized worker for organizational duties. Completion of this form is required for personnel recordkeeping, access provisioning, and for consent to verifications described below.

Personal Information

Date of Birth:   Employee ID (if assigned):

Primary Phone:   Email:

Emergency Contact

Relationship:   Phone:

Position Information

Reporting Manager:   Proposed Start Date:

Full-Time    Part-Time    Contractor    Temporary

Building Access    Information Systems    Confidential Records    Driving Privileges

Certifications, Licenses, and Qualifications

Primary Certification Name:   Issuing Body:

Number / ID:   Expiration Date:

Employment History

Employer 1

Job Title:   From: To:

Employer 2

Job Title:   From: To:

Education

Major / Field of Study:   Graduation Date:

Professional References

Reference 1

Relationship:   Phone:   Email:

Reference 2

Relationship:   Phone:   Email:

Reference 3

Relationship:   Phone:   Email:

Legal Disclosures & Authorizations

At-Will Employment: I understand that if I am granted employment, my employment will be on an at-will basis unless otherwise set forth in a separate written agreement signed by an authorized representative of the organization. This means that either I or the organization may terminate the employment relationship at any time, with or without cause or notice, unless prohibited by law.

Equal Opportunity: The organization is an equal opportunity employer and does not unlawfully discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable law.

Background and Verification Authorization: I authorize the organization and its agents to verify any and all information provided on this form, including but not limited to employment history, educational credentials, professional licenses, references, criminal background checks, motor vehicle records, and other records necessary to establish my suitability and accreditation for assigned duties. I authorize former employers, educational institutions, licensing bodies and references to release records and information to the organization. I release such parties from any liability for providing such information.

I consent to background checks and verifications as described above.

Disclosure of Convictions/Adjudications: Have you been convicted of, or pled guilty or nolo contendere to, any felony or misdemeanor that has not been annulled, expunged, or sealed?   Yes   No

Applicant Certification

I certify that all information provided in this Employee Worker Accreditation Form is true, complete and correct to the best of my knowledge. I understand that falsification, omission or misrepresentation of information may result in denial of accreditation, withdrawal of offers, or termination of employment if discovered after hire.

I further acknowledge that completion of this form does not constitute a promise of employment or accreditation; final accreditation is contingent upon verification of qualifications, satisfactory background checks, and compliance with organizational policy.

Authorization to Contact Previous Employers: I authorize the organization to contact my previous employers and supervisors for purposes of verification and reference.

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