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Employment Good Repute Declaration

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EMPLOYMENT GOOD REPUTE DECLARATION

Personal Information

Full Legal Name:

Phone:

Email:

Date of Birth:

Identification (last 4 digits of SSN or national ID):

Position Information

Department:

Reporting Manager:

Proposed Start Date:

Proposed Salary:

Work Location:

Employment History (Most Recent Employer)

Title:

Start Date:

End Date:

Supervisor Name:

Supervisor Phone:

Employment History (Prior Employer)

Title:

Start Date:

End Date:

Supervisor Name:

Supervisor Phone:

Education

Graduation Date:

Major/Field:

Professional References

Phone:

Email:

Relationship:

Phone:

Email:

Relationship:

Phone:

Email:

Relationship:

Declarations of Good Repute

Please indicate any of the following circumstances that apply to you. For each item you check, provide full details in the corresponding explanation field below. If none apply, leave unchecked.

I have been convicted of a felony or misdemeanor (excluding minor traffic offenses).

I currently have pending criminal charges or ongoing investigations.

I have been the subject of formal disciplinary action, suspension, or termination for cause by any prior employer.

Any professional license, certification or credential issued to me has been revoked, suspended, or subject to disciplinary proceedings.

I have knowingly falsified employment, education, credential, or other records provided to an employer or licensing authority.

I have filed for bankruptcy, or been declared insolvent within the past seven years.

A security clearance or similar access authorization held by me has been denied, suspended or revoked.

I have been disciplined for drug or alcohol policy violations by an employer or licensing authority within the last five years.

Authorizations, Consents and Declarations

By checking the boxes below and signing this Declaration, I expressly authorize the prospective employer and its agents to obtain and verify information about my employment history, education, professional credentials, criminal record, credit history where job-related, and any other information necessary to determine my suitability for employment. I release from liability any person, including prior employers, who provides information in good faith pursuant to this authorization.

I consent to a comprehensive background check, including criminal record search and verification of prior employment and education.

I consent to contact of the references and supervisors listed herein.

I consent to a credit check where the position requires financial responsibility or access to funds.

I understand that any misrepresentation, omission, or falsification of information provided in this Declaration may constitute grounds for refusal of employment, or if employed, termination for cause. I acknowledge that employment, if offered, may be conditioned upon successful completion of background checks, verification of credentials, and any required clearances.

Employment Policy Statements

At-Will Employment: If employed, I understand that my employment with the employer is at-will, which means that either the employer or I may terminate the employment relationship at any time, with or without cause or prior notice, unless a written agreement states otherwise.

Equal Opportunity: The employer is an equal opportunity employer. Employment decisions are made without regard to protected characteristics. Applicants are evaluated on the basis of qualifications relevant to the position.

Applicant Certification

I certify under penalty of perjury that the information provided in this Employment Good Repute Declaration and any attachments is true, complete and correct to the best of my knowledge. I understand that the employer may rely on this Declaration in making employment decisions. I further certify that I am authorized to sign this document and that I have not omitted information that would be material to my fitness for employment.

Applicant Name:

Signature:

Date:

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What an Employment Good Repute Declaration Is

An Employment Good Repute Declaration is a signed statement in which an applicant or employee affirms facts about their conduct, qualifications, and history relevant to a role's standards of integrity and reputation. Employers commonly use it to confirm disclosure of disciplinary actions, criminal convictions, regulatory sanctions, or professional license issues. The declaration may permit background checks and references, create an audit trail for hiring decisions, and serve as a record for compliance with industry rules or internal policies.

Why this declaration matters for employers and applicants

The declaration documents candidate assertions, reduces hiring risk by recording disclosures, and supports regulatory compliance for roles that require good repute or licensure. It creates a reproducible record usable in audits, investigations, or dispute resolution.

Why this declaration matters for employers and applicants

Who completes and relies on the Employment Good Repute Declaration

Employers, HR teams, regulated licensees, and candidates use this document to establish factual statements about reputation and history before hiring or credentialing.

  • Employers and HR departments vet applicants for roles requiring trust, licensure, or financial responsibility.
  • Licensing and regulatory compliance teams collect disclosures to meet industry or state requirements.
  • Job applicants and current employees provide sworn statements and consent for background checks.

Clear, consistent use of the declaration protects organizations and individuals by documenting disclosures, consent, and the date of acknowledgement.

Core components to include in the declaration

A practical Employment Good Repute Declaration combines factual statements, consent language, a verification clause, and signature elements so it can be relied on for hiring, licensing, or audit purposes.

Declaration Statement

A concise affirmative statement signed by the declarant confirming the truth of disclosed facts and acknowledgment that false statements may have consequences.

Background Summary

A section listing prior employment, disciplinary actions, criminal convictions, license suspensions, or investigations relevant to fitness for the position.

Consent for Checks

Clear, dated consent permitting employer-conducted background checks, reference contacts, and verification of licenses or credentials.

Authorization for Disclosure

Language allowing third parties (former employers, licensing boards) to release verification information to the requesting employer for evaluation purposes.

Attestation and Remedies

A clause stating that the declarant attests to accuracy, understands consequences for misrepresentation, and acknowledges employer remedies for false statements.

Signature Block

Typed full legal name, handwritten or electronic signature, printed name, date, and contact information; include notary or witness fields if required.

Essential information to collect on the form

Full Legal Name: As shown on government ID
Date of Birth: MM/DD/YYYY format
Social Security Number: For background checks only
Position Applied: Job title or role
Disclosure Details: Concise description of events
Signature and Date: Signer identity confirmation

Step-by-step: completing the declaration

Follow these steps in order to prepare a clear, legally defensible declaration and to collect valid consent for verification.

  • 01
    Gather documents: Collect IDs, licensing records, and prior-employer contact information.
  • 02
    Draft disclosures: Summarize events with dates and jurisdictions.
  • 03
    Review consent: Ensure background-check language is explicit and dated.
  • 04
    Sign and date: Execute under the chosen signature method and record the timestamp.

Configuring an online workflow for collection and review

Design the digital workflow to capture fields, authentication, routing, and storage consistently for auditability.

Field Configuration
Required fields Make name, date, disclosures mandatory
Authentication Email + SMS code recommended
Routing HR reviewer then compliance approver
Storage Encrypted, access-controlled archive

Where to send the completed declaration

Route the executed declaration to the appropriate internal and external recipients to complete vetting and recordkeeping.

  • HR Record: Attach to the candidate's personnel file.
  • Compliance Team: Forward for regulatory review if required.
  • Third-Party Check Vendor: Send consented data for background screening.
  • Legal Counsel: Deliver copies for disputes or audits.

Digital signing and eSubmission considerations

Choose a platform that supports secure signing, audit trails, and required integrations for your compliance needs.

  • Authentication Options: Email link, SMS code, or stronger multi-factor
  • Integrations: Connectors for HRIS, ATS, and cloud storage
  • Document Formats: PDF and DOCX accepted

Ensure the platform you select can produce a tamper-evident signed PDF, capture an audit trail, and integrate with your storage or HR systems.

Typical timelines and processing expectations

Plan for time to review disclosures, perform background checks, and for candidate response when additional information is needed.

Candidate completion:

1–3 business days typical

Background checks:

3–7 business days typical

Regulatory review:

2–4 weeks depending on agency

Notarization or RON:

Same day to 5 business days

Record retention start:

Effective date recorded on signature

Common mistakes to avoid when preparing the declaration

  • Leaving identification fields incomplete, which delays background checks and verification processes.
  • Using vague language in disclosures; ambiguous descriptions can undermine reliance on the declaration.
  • Failing to obtain explicit consent for third-party checks, creating legal or procedural obstacles.
  • Ignoring state notarization or witness rules when the declaration must function as an affidavit.

Consequences of inaccurate or missing declarations

Employment Sanctions: Termination or disciplinary action
Criminal Liability: Perjury or fraud charges possible
I-9 Penalties: I-9 fines $281–$2,789 (8 CFR §274a.2)
Licensing Risk: License revocation or suspension
Civil Exposure: Damages for negligent hiring
Background Failure: Disqualification from hire

Use-case examples showing how the declaration is applied

Practical scenarios illustrate how employers and regulated professionals use the declaration to document fitness and consent for checks.

Healthcare Candidate

A nurse applicant discloses a prior license suspension

  • employer verifies dates with the state board
  • the declaration and board response are kept six years under HIPAA and institutional policy to support credentialing continuity.

Finance Role

A candidate for a fiduciary role discloses a past disciplinary action

  • the firm obtains references and regulatory records under consent
  • the declaration documents the decision and mitigations for audit evidence.

Pricing snapshot for common eSignature providers

Basic pricing and feature differences for leading eSignature vendors; signNow appears first to allow direct feature comparison for document collection workflows.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about the Employment Good Repute Declaration

Answers to common questions about e-signing, notarization, legal validity, and resolving disputes related to the declaration.


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