Employment Verification Request

EMPLOYMENT VERIFICATION REQUEST

Use this form to request verification of employment for an individual. The Requesting Party completes the Requesting Party section. The Subject/Employee completes the Authorization and Applicant Certification. The Employer completes the Employer Verification section and returns this form to the Requesting Party. Information disclosed pursuant to this authorization shall be limited to the scope described herein.

Requesting Party

Subject / Employee — Personal Information

Position Information to be Verified

Employment History (Most Recent Employers)

Education

References (Professional)

Legal Disclosures and Statements

At-Will Employment: Nothing in this form alters any employment-at-will relationship between the employee and any employer. The employer retains the right to terminate employment at any time, with or without cause, subject to applicable law.

Equal Opportunity: The Requesting Party and the Employer represent that they comply with applicable equal opportunity laws and will not use information provided under this verification for unlawful discrimination.

Authorization to Release Information

I hereby authorize the Employer named above and any prior employers listed on this form to release and discuss my employment records and related information with the Requesting Party for the purpose stated above. The scope of information authorized for disclosure includes dates of employment, job title(s), compensation or wage history, status of employment, reason for separation, eligibility for rehire, and factual performance or attendance information.

I understand that this authorization is voluntary, that the information will be used only for the specified purpose, and that I may revoke this authorization at any time by providing written notice to the Requesting Party. Revocation will not apply to information already released in response to this authorization prior to receipt of the revocation. By signing below I release and hold harmless the Employer and the Requesting Party from any liability for disclosure of the authorized information.

Applicant Certification

I certify under penalty of perjury that the information provided on this form is true, complete and correct to the best of my knowledge. I authorize the Requesting Party and Employer to verify any information provided. I understand that providing false information may subject me to adverse action under applicable policies or law.

Employer Verification (To be completed by Employer HR Representative)

(This section is for use by the Employer. Please complete all applicable fields and return to the Requesting Party.)

Employer Representative attests under penalty of perjury that the foregoing information is true and correct to the best of the representative's knowledge and that disclosure of such information is authorized under company policy and applicable law.

By submitting this form, the Requesting Party acknowledges responsibility for maintaining the confidentiality of the information received and for any further disclosures that may be subject to statutory limitations. The Employer is not required to provide information beyond the scope of this authorization and may redact personally sensitive data except as necessary for verification.

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