Employment Testing History

EMPLOYMENT TESTING HISTORY

Personal Information

Position Information

Desired Start Date:    Proposed Salary/Wage:

Employment Testing History — Overview

Use the following entries to disclose all employment-related tests, examinations, or evaluations administered by previous employers, testing agencies, licensing boards, or other entities. Employment-related tests include, but are not limited to, pre-employment drug and alcohol screening, criminal background checks, motor vehicle record checks, physical examinations, functional capacity evaluations, psychological evaluations, polygraph examinations, skills or certification exams, and any testing that affected eligibility for hire, continued employment, certification, licensing, or promotion.

Test Entry 1

Type of Test:   Date Administered:

Test Entry 2

Type of Test:   Date Administered:

Test Entry 3

Type of Test:   Date Administered:

Test Entry 4

Type of Test:   Date Administered:

Test Entry 5

Type of Test:   Date Administered:

Test Entry 6

Type of Test:   Date Administered:

Prior Employment History (Minimum Two Employers)

Employer 1

Employer 2

Education

Professional References (Three)

Legal Disclosures and Authorizations

At-Will Employment: I understand that completion of this form does not constitute an offer of employment and that, if hired, my employment will be at-will unless a written agreement signed by an authorized company representative states otherwise.

Equal Opportunity: I acknowledge that the employer is an equal opportunity employer and does not discriminate in hiring or employment on the basis of legally protected characteristics.

Confidentiality and Use of Records: I understand that testing and evaluation records are maintained in personnel files or secure records systems. Information disclosed on this form will be used to evaluate my suitability for employment and may be shared only with those with a legitimate business need.

Consent to Verify Testing Records and Background Checks

By checking the box below and signing, I authorize the prospective employer, its agents, and designated third-party administrators to obtain, inspect, and verify records of any employment-related tests, evaluations, and results disclosed in this form. This authorization includes, but is not limited to, contact with prior employers, testing laboratories, licensing boards, and other entities that maintain testing records. I authorize those entities to release any such records and confirm any information provided herein.

I further acknowledge that I may be required to provide additional documentation or sign additional releases specific to certain types of tests (for example, drug/alcohol testing or licensing board records). Refusal to sign required releases or provide information may affect the employer's decision regarding employment.

Disclosure of Test Failures, Refusals, or Adverse Actions

Have you ever failed, refused, or been the subject of any adverse employment action as the result of an employment-related test, examination, or evaluation?

Applicant Certification and Authorization

I certify under penalty of perjury that all information contained in this Employment Testing History is true, correct, and complete to the best of my knowledge. I understand that intentional misrepresentation, omission, or falsification of information may be grounds for refusal to hire or immediate termination of employment if discovered after hire.

I authorize the release of necessary information to verify the accuracy of the statements provided and to obtain any testing records or reports as described above. I understand that the employer may rely on the information provided in making hiring decisions.

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