Can this form be signed electronically?

Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA in most states, provided the signature demonstrates intent, consent, attribution, and records are retained in a reproducible form.

When is notarization required?

Notarization is only required where state law or a licensing authority specifically requires it; verify with the applicable state agency. Some states require notarized or witnessed declarations for certain licensing processes.

What if the offence is expunged or sealed?

If a record is expunged or sealed, disclose only as required by statute. Federal and many state laws limit use of expunged records; consult counsel before requesting sealed-record details.

How long must employers keep the form?

Retention varies: keep for the employment term plus at least 3 years for typical personnel files (IRC §6501(a)); if PHI is present, retain 6 years per 45 CFR §164.530(j).

Can an applicant withdraw or correct a declaration?

Applicants may request corrections; employers should maintain versioned records showing the original, the correction request, and final disposition to preserve auditability.

What authentication level is recommended?

Use stronger authentication (SMS, MFA, or ID verification) for sensitive disclosures and when the record may be used for regulatory decisions; maintain an audit trail with timestamp and signer attribution.

Electronic Signature
Templates
HR
Employment Offence Declaration

Employment Offence Declaration

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EMPLOYMENT OFFENCE DECLARATION

Employee Name: Employee ID (if applicable):

This Employment Offence Declaration must be completed fully and accurately. Any failure to disclose required information may result in withdrawal of an offer, disciplinary action, or termination of employment. Your signature at the end certifies the truthfulness and completeness of the statements and authorizes the employer to verify information and conduct background inquiries as described below.

Personal Information

Full Legal Name Residential Address Phone Number Email Address

Position Information

Position Title Department Reporting Manager Proposed Start Date Proposed Salary / Rate

Employment History (Most Recent First)

Employer 1

Company Name Title / Position Dates Employed Primary Responsibilities Reason for Leaving

Employer 2

Company Name Title / Position Dates Employed Primary Responsibilities Reason for Leaving

Education

Highest Degree or Certification Institution Graduation or Completion Date

Professional References

Reference 1

Reference 2

Reference 3

Offence Disclosure

Please indicate whether any of the following apply to you. For each box checked, provide full details in the corresponding description field below, including dates, jurisdictions, case numbers (if known), disposition, sentence or sanction, and the identity of any employer or licensing authority involved.

I have been convicted of a criminal offence

I am currently charged or have pending criminal proceedings

I have been the subject of an internal investigation by a previous or current employer

I have been disciplined, suspended, or terminated for misconduct by an employer

I have had a professional license or certification suspended, revoked, or otherwise sanctioned

Other offence, finding, or administrative action not described above

Legal Disclosures

At-Will Employment: I understand that, unless expressly provided otherwise in a separate written agreement signed by an authorized representative of the employer, my employment is at-will and may be terminated by me or the employer at any time, with or without cause or notice.

Equal Opportunity: I acknowledge that the employer is an equal opportunity employer and does not discriminate on the basis of legally protected characteristics. Disclosure of offences will be considered only to the extent permitted by applicable law and consistent with the employer's obligations.

Applicant Certification and Authorization

I certify under penalty of perjury that the information provided in this Employment Offence Declaration is true, complete, and correct to the best of my knowledge. I acknowledge that the employer may rely on this declaration in determining eligibility for employment or continued employment. I understand that a false statement, omission, or misrepresentation may be grounds for denial of employment or immediate termination if I have been hired.

Authorization to Investigate: I authorize the employer, its agents, and representatives to contact prior employers, educational institutions, licensing bodies, law enforcement agencies, and other entities to verify all information provided and to obtain background, criminal records, disciplinary records, and other job-related information. I release the employer and its agents from liability for conducting such inquiries in good faith.

Consent to Background Check: I consent to the employer performing background and record checks as described above.

If you checked any offence box above, you must provide complete details. The information provided may be subject to verification and the employer will evaluate relevance and timing of any offence in accordance with applicable law and legitimate business needs.

Supplemental Offence Entries (Optional — up to 3)

Offence Entry 1

Offence Entry 2

Offence Entry 3

Acknowledgment

By signing below I acknowledge that I have read and understand this Employment Offence Declaration, that I have provided all required disclosures, and that the employer may take adverse employment action where permitted by law if disclosures are found to be incomplete or inaccurate.

Printed Name:

Signature:

Date:

What the Employment Offence Declaration Is and When It Applies

An Employment Offence Declaration is a written statement used by employers or applicants to disclose prior employment-related offences, disciplinary actions, or criminal conduct that may be relevant to hiring, retention, or credentialing decisions. The form records the declarant's name, dates, a description of the offence or incident, the jurisdiction, and any employment sanctions imposed. Employers typically collect this declaration as part of background-screening, licensing, regulatory compliance, or internal investigation workflows to document the applicant’s or employee’s history and the employer’s decision-making record.

Why this Declaration Matters for Employers and Applicants

The declaration creates a formal, contemporaneous record that supports lawful hiring decisions, reduces legal risk, and documents compliance with internal policies or regulatory obligations. Proper completion helps employers demonstrate nondiscriminatory practices and gives applicants a clear opportunity to explain past issues in their own words.

Who Typically Completes or Reviews the Employment Offence Declaration

Employers, HR professionals, hiring managers, licensing boards, compliance officers, and prospective employees commonly interact with this form.

Prospective employees or applicants providing personal disclosure during onboarding or application screening.
Human resources and hiring managers who evaluate disclosures against policy and role requirements.
Regulatory or licensing bodies reviewing applicant fitness for regulated positions.

Use the form only where permitted by law and consistent with background-check consent and consumer disclosure requirements.

Step-by-step: Filling Out the Employment Offence Declaration

Follow these four steps to complete the declaration accurately and consistently.

01

Identify Parties: Enter full legal name of declarant and employer or agency.
02

Describe Offence: Summarize the incident with date, location, and charges or findings.
03

State Outcome: Note disciplinary actions, convictions, dismissals, or acquittals.
04

Sign and Date: Sign, date, and include contact details for follow-up verification.

Core elements every professional Employment Offence Declaration should include

A complete declaration follows a predictable structure to be useful for HR decision-making, background checks, and compliance reviews.

Header

Form title, version date, and space for an internal tracking or file number to link the declaration to applicant records.

Declarant Identity

Full legal name, aliases, date of birth, and contact information to aid accurate identity matching.

Incident Data

Date(s), location(s), and short factual description of the offence or allegation to clarify scope and timeline.

Legal Outcome

Disposition details such as conviction, plea, acquittal, dismissal, probation, or sealed/expunged status with dates.

Employment Action

Any employer-imposed sanctions, termination, suspension, or remediation steps previously taken and their dates.

Signatures and Declarations

Declarant signature, printed name, date, and a checkbox affirming accuracy under penalty of perjury where appropriate.

Data points you must collect on the form

Name: Full legal name

DOB: MM/DD/YYYY

Contact: Phone and email

Offence Date: Exact or approximate date

Disposition: Conviction, dismissal, or expunged

Signature: Signed and dated

Legal and operational risks of incomplete or incorrect declarations

Hiring Liability: Misstated facts can lead to negligent hiring claims or regulatory penalties

Privacy Violations: Improper handling of health or sealed records can trigger HIPAA or state privacy enforcement

Perjury Exposure: False statements on sworn declarations may create criminal exposure in some jurisdictions

Discrimination Risk: Incomplete process documentation can undermine defense against disparate-treatment claims

Recordkeeping Gaps: Missing audit trails impair internal investigations and external audits

Regulatory Fines: Failure to follow statutorily required procedures can produce agency fines or license actions

Common mistakes to avoid when preparing the declaration

Failing to use precise dates or jurisdictional detail, which blocks record retrieval
Mixing allegations and findings without separating statements of fact from opinion
Omitting signature date or failing to obtain required witness/notary where required
Storing completed forms insecurely or without an audit trail

Typical processing flow for submission and review

Most organizations follow a simple send-review-file sequence to collect and act on declarations.

Upload: Sender uploads declaration to the HR or case management system
Assign Reviewer: HR or compliance assigns a reviewer for evaluation
Decision: Hiring or disciplinary decision is recorded with rationale
Archive: Finalized record stored with access controls and audit trail

Configuring an online workflow for secure collection

Set up routing and authentication to match the document's sensitivity and legal requirements.

Field	Configuration
Authentication	Email + optional SMS code
Routing	HR → Legal → Hiring Manager
Retention Tag	Apply retention policy metadata
Audit Trail	Enable IP/time-stamp logging

Choosing technical features for secure electronic handling

Use a platform that offers secure storage, auditable logs, and appropriate signer authentication.

Authentication: Multi-factor options for high-risk disclosures
Encryption: TLS in transit and AES-256 at rest
Audit Trail: Timestamped event history and downloadable certificate

For healthcare or regulated roles, ensure the platform supports HIPAA workflows and a BAA; for FDA-regulated records, consider 21 CFR Part 11 controls.

Timing considerations and response windows

Be aware of statutory, investigative, and internal deadlines that affect action on a declaration.

Submission Timing:

Provide declaration at application or as soon as an issue is identified

Background Checks:

Allow 3–10 business days for record retrieval in many jurisdictions

Internal Review:

Set a 7–30 day window for HR evaluation depending on complexity

Appeal Period:

Offer reasonable time for applicant rebuttal per company policy

Retention Start:

Retention typically begins on the decision or filing date

Comparison: eSignature vendor pricing and basic feature signals

High-level vendor pricing and feature presence for consideration when choosing an eSignature solution for sensitive declarations; signNow is listed first per platform comparison conventions.

	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	Yes, 7-day trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year limit	Varies	Varies	Varies

Sample scenarios illustrating common uses of the declaration

Two short examples show how organizations apply the form in practice.

Case Study 1

A healthcare clinic required a disclosure as part of credentialing to align with state licensing rules.

The applicant disclosed a misdemeanor from five years prior.
The clinic documented the incident, verified disposition, applied mitigation steps, and retained the record for six years per HIPAA and state rules.

Case Study 2

A property manager requested a declaration during tenant screening to evaluate prior evictions.

The tenant provided details and dates.
The manager used the verified disclosure to make a leasing decision, recorded the rationale in the applicant file, and kept the documentation per state landlord-tenant retention guidelines.

Frequently asked questions about the Employment Offence Declaration

Answers to common concerns about validity, disclosure scope, and electronic handling.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are generally enforceable under the ESIGN Act (15 U.S.C. §7001) and UETA in most states, provided the signature demonstrates intent, consent, attribution, and records are retained in a reproducible form.
When is notarization required?
Notarization is only required where state law or a licensing authority specifically requires it; verify with the applicable state agency. Some states require notarized or witnessed declarations for certain licensing processes.
What if the offence is expunged or sealed?
If a record is expunged or sealed, disclose only as required by statute. Federal and many state laws limit use of expunged records; consult counsel before requesting sealed-record details.
How long must employers keep the form?
Retention varies: keep for the employment term plus at least 3 years for typical personnel files (IRC §6501(a)); if PHI is present, retain 6 years per 45 CFR §164.530(j).
Can an applicant withdraw or correct a declaration?
Applicants may request corrections; employers should maintain versioned records showing the original, the correction request, and final disposition to preserve auditability.
What authentication level is recommended?
Use stronger authentication (SMS, MFA, or ID verification) for sensitive disclosures and when the record may be used for regulatory decisions; maintain an audit trail with timestamp and signer attribution.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now