Employment Not Eligible Form

EMPLOYMENT NOT ELIGIBLE FORM

Applicant Identification

Applicant Name:

Date of Birth:    Applicant ID (if applicable):

Position Information

Position Applied For:

Department:    Hiring Manager:

Requisition Number:    Date of Application:

Interview Date (if applicable):

Employment History (Most Recent Two Employers)

Education

Highest Degree:

Institution:

Graduation Date:

Professional References (Three)

Determination of Ineligibility

Determination (select all that apply):

Basis for Determination (select all that apply):

Legal Notices, Certifications, and Applicant Rights

At-Will Notice: Employment with the organization is at-will. Nothing in this determination alters or creates an employment contract or alters any at-will status unless expressly approved in writing by an authorized company officer.

Equal Opportunity: This determination was made in accordance with applicable non-discrimination and equal employment opportunity obligations. Criteria used for this decision were related to the duties and responsibilities of the position and the employer's legitimate business needs.

Applicant Certification: I certify that I have received notice of this ineligibility determination. I understand the reason(s) checked above and have been provided an opportunity to respond in writing within seven (7) calendar days of receiving this notice.

Authorization to Verify: By signing below, I authorize the employer to contact prior employers, education institutions, and references, and to obtain or review background checks, consumer reports, and drug testing results as applicable to this determination.

Confidentiality: This document and accompanying investigation records are confidential and maintained in accordance with the employer's record retention and privacy policies.

HR Review and Administrative Record

HR Reviewer Name:

HR Reviewer Title:    Review Date:

Applicant Response (Optional)

Sign Now