Employment Licence Request

EMPLOYMENT LICENCE REQUEST

Personal Information

Applicant Name:

Employee ID (if applicable):

Date of Birth:

Position Information

Reporting Manager:

Employment Start Date:

Full-time Part-time Contract Temporary

Licence Request Details

Type of Licence Requested (check all that apply):

Professional / Occupational Licence (e.g., nursing, engineering) Driver / Commercial Vehicle Licence Security / Background-Screened Licence Other

Request Category: New Renewal Replacement

Licence Expiration Date:

Current Licence Status: Active Suspended Expired Not currently held

Employer Support Requested: Fee reimbursement Paid time off for testing/training Employer-provided training

Yes No

Supporting Documents

Copy of current licence / certificate Completed licensing application form Academic transcript or proof of qualification Other supporting documents (attach)

Employment History

Previous Employer 1

Dates Employed: From To

Previous Employer 2

Dates Employed: From To

Education & Certifications

Graduation Date:

References (Professional)

Legal Disclosures & Authorizations

At-Will Employment: Nothing in this licence request or any action taken by the employer in connection with this request alters the at-will employment relationship between the employee and the employer. Employment is at-will and may be terminated by either party with or without cause or notice, subject to applicable law.

Equal Opportunity: The employer provides equal employment opportunities and does not discriminate on the basis of protected characteristics. Licensing decisions will be administered in a nondiscriminatory manner in accordance with applicable law.

Authorization to Verify and Obtain Records: By submitting this request, I authorize the employer and its designated agents to contact licensing bodies, educational institutions, previous employers, and references to verify the information provided and to obtain any records relevant to the licensing request, including but not limited to licensing history, disciplinary records, educational verification, and employment verification, subject to applicable legal limitations.

Background Screening Consent: I consent to any background checks or fingerprinting required by the issuing authority or the employer as a condition of obtaining or maintaining the requested licence. I understand that adverse information may affect the employer's decision to support this request.

Applicant Acknowledgement: I certify that all information provided in this form is true, complete, and accurate to the best of my knowledge, and that I will notify Human Resources promptly of any changes.

Applicant Certification & Declaration

I certify under penalty of perjury that the statements and representations made in this Employment Licence Request are true and correct. I agree to comply with the employer’s policies and with all conditions imposed by the issuing authority as a condition of licensure. I acknowledge that any material misrepresentation or omission may result in disciplinary action, up to and including termination.

I further authorize the employer to incur reasonable administrative costs or to process payment for fees on my behalf if approved, subject to separate written authorization. I understand that any employer payment or reimbursement may be conditioned upon continued employment or other terms to be specified in a separate agreement.

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