Employment Verification Document

EMPLOYMENT VERIFICATION DOCUMENT

Requestor Information

Employee Information

Employee Name:   Date of Birth:

Position Information

Reporting Manager:   Start Date:   End Date (if applicable):

Currently Employed    Terminated    On Leave    Full-Time    Part-Time

Employment History (Most Recent Employers)

Title:   Start Date:   End Date:

Title:   Start Date:   End Date:

Education

Graduation Date:

References

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Phone:    Email:    Relationship:

Legal Disclosures

At-Will Employment Statement: Employment with the employer is at-will, unless otherwise set forth by a written agreement signed by an authorized representative. This verification document does not alter the at-will nature of employment.

Equal Employment Opportunity Statement: The employer does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or any other protected characteristic under applicable law in employment practices.

Applicant Certification & Authorization

I certify that all information provided in this document is true and complete to the best of my knowledge. I authorize the employer to release employment-related information to the named requestor for the purpose of verification. I further authorize the employer and its agents to contact prior employers and references, and to conduct customary background and employment verification checks where permitted by law.

Employee Consent to Release: I authorize release of the information described above.

Employer Verification Section

Employer Representative:   Title:

Phone:    Email:    Date of Verification:

By signing below, the employer representative certifies that the information provided in this document is true, complete, and accurate to the best of their knowledge, and that disclosure of such information is permitted under company policy and applicable law.

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