Employment Suitability Declaration

Employment Suitability Declaration

Personal Information

Full Legal Name:

Position Information

Anticipated Start Date:    Provisional Salary/Rate:

Employment History (Most Recent First)

Supervisor:    Phone:

Start Date:    End Date:    Title:

Supervisor:    Phone:

Start Date:    End Date:    Title:

Education

Graduation Date:

References

Please provide three professional references.

Legal Disclosures and Authorizations

At-Will Employment Statement: I understand that if hired, my employment will be on an at-will basis, meaning either I or the employer may terminate the employment relationship at any time, with or without cause or notice, except as otherwise provided by a written agreement signed by an authorized representative of the employer. I acknowledge that no person other than an authorized representative has the authority to alter this at-will relationship.

Equal Opportunity: The employer is an equal opportunity employer. Decisions relating to recruitment, hiring, promotion, compensation, benefits, training and termination are made without regard to race, color, religion, sex, national origin, age, disability, genetic information, marital status, military status, or any other characteristic protected by law.

Fitness for Duty and Accommodations: Can you perform the essential functions of the position applied for, with or without reasonable accommodation?    With reasonable accommodation    Without accommodation    Cannot perform the essential functions

Criminal Conviction Disclosure: Have you ever been convicted of a felony or been adjudicated guilty of a crime that has not been expunged?    Yes    No

Employment Restrictions / Conflicts: Are you subject to any non-compete, non-solicitation, or confidentiality obligations that would affect your ability to perform the duties of the position?    Yes    No

Drug and Alcohol Testing: I acknowledge that pre-employment drug and alcohol testing may be required as a condition of employment and I consent to such testing in accordance with employer policy. I further consent to post-accident or reasonable-suspicion testing if employed.    I consent

Background and Verification Authorization: I authorize the employer and its agents to obtain information regarding my background, including but not limited to employment verification, education verification, credit history where job-related, motor vehicle records where job-related, criminal record checks, and other lawful inquiries. I authorize all references, former employers, educational institutions, and other persons to provide any information requested about me and I release them from liability for providing such information. I understand that information obtained will be used to evaluate my suitability for employment.

Applicant Certification: I certify that the information I have provided on this Employment Suitability Declaration and any accompanying documents is accurate and complete to the best of my knowledge. I understand that false statements, material omissions, or misrepresentations may result in refusal to hire or termination of employment. I agree to notify the employer of any change in the information provided that occurs prior to employment.

Applicant Authorization and Release

By signing below I expressly authorize the employer and its designated representatives to conduct the background checks described above. I further authorize the release of any records or information to the employer. I release the employer, its agents, and any person providing information from any liability for damage that may result from furnishing such information.

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