Employment Disqualification Form

EMPLOYMENT DISQUALIFICATION FORM

Parties and Identifying Information

Employer Name:

Employee Name:

WHEREAS

WHEREAS, Employer has responsibility for staffing and compliance for the position identified below and has authority to determine employment eligibility and continued employment; and

WHEREAS, the Employee has been evaluated with respect to qualifications, background checks, regulatory requirements, and other job-related criteria; and

WHEREAS, Employer has determined that the Employee is disqualified from performing certain duties or holding the position specified herein for reasons set forth in this document, and the parties wish to document those determinations and the consequences in writing.

Position and Basis for Disqualification

Effective Date of Disqualification:   Reason(s) for Disqualification (check all that apply):

Scope of Work / Scope of Disqualification

Scope of Disqualification — state the specific duties, locations, systems, or responsibilities from which the Employee is disqualified:

Payment Terms and Financial Consequences

Applicable Compensation Adjustments or Withholdings (if any): the parties agree that amounts identified below are authorized under applicable law and the employment agreement.

Term and Termination

Disqualification Start Date:    Expected End Date (if any):

Notice Period for Termination of Disqualification (if applicable):

Termination for Cause: Employer may terminate or extend the disqualification earlier upon demonstration of material breach of policy, new disqualifying information, or satisfaction of remediation conditions as set forth herein.

Confidentiality

The Employee acknowledges that this determination, the underlying investigatory materials, and any remedial or corrective measures may contain confidential business information. Employee agrees not to disclose confidential information except as required by law. Employee further agrees not to use confidential information to the detriment of Employer and will return all Employer property upon request.

Representations and Certifications

The Employee certifies that all information provided to Employer that is relevant to this determination is true and complete to the best of Employee's knowledge. Employee understands that intentional falsification may constitute separate grounds for disciplinary action, up to and including termination.

Governing Law; Entire Agreement

This form and any dispute arising out of or related to it shall be governed by the laws of the State identified by Employer below without regard to conflict-of-law principles. This document, together with any referenced employment agreement provisions expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written representations.

Miscellaneous Provisions

Severability: If any provision of this form is held invalid, illegal, or unenforceable, the remaining provisions shall continue in full force and effect. Waiver of any provision must be in writing signed by the party waiving the provision.

No Admission of Liability: Execution of this form is not and shall not be construed as an admission of liability by Employer or Employee.

Acknowledgment and Consent

By signing below, Employee acknowledges receipt of this Employment Disqualification Form, affirms that Employee has had the opportunity to review and ask questions, and understands the consequences described herein.

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