Employment Experience Verification Form

EMPLOYMENT EXPERIENCE VERIFICATION FORM

This Employment Experience Verification Form is a formal request to confirm employment-related information for the individual named below. Applicant Name:

Personal Information

Position Information

Employment History (Provide at least two employers)

Employer 1

Position/Title:   Dates Employed (From - To):

Employer 2

Position/Title:   Dates Employed (From - To):

Previous Employer Verification (To be completed by Employer Representative)

For Employer (Name):

Employee Name Verified:

Employment Dates Verified (From):    (To):

Last Position/Title:    Last Base Salary/Wage:

Separation Type:    Eligible for Rehire? Yes

Verifier Name:    Title:

Verifier Phone:    Verifier Email:

Education

References (Professional)

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Legal Disclosures

At-Will Employment: Nothing in this form creates a contract of employment. Employment, if offered, may be terminated by the employer or the employee at any time, with or without cause or notice, unless a written agreement signed by authorized representatives of the employer states otherwise.

Equal Employment Opportunity: The employer verifies information in compliance with applicable federal, state, and local laws prohibiting discrimination. Responses to this verification will be based solely on verifiable employment facts.

Applicant Certification and Authorization

I certify that all information I have provided on this form is true, complete, and correct to the best of my knowledge. I understand that any misrepresentation or omission of fact may result in adverse action, including denial of employment or termination if employed.

Authorization to Release Information: I hereby authorize my current and former employers, educational institutions, references, and other relevant third parties to release to the requesting employer any and all information requested in this form. I release those parties from liability for providing such information in good faith.

Background Check Authorization: I consent to a background investigation, which may include verification of education, employment history, criminal record, and other records as permitted by law. I understand that information obtained will be used only for employment-related decisions and in accordance with applicable law.

Applicant Authorization: I authorize release of the information requested above.    I authorize a background check as described above.

Applicant Printed Name:    Date of Birth (optional):

Applicant Signature (by signing below, I attest to the accuracy of this authorization and understand the statements above): see signature block at the end of the form.

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