HR I.C.A. Form

HR I.C.A. Form

Personal Information

Date of Birth:    Last 4 digits of SSN:

Position Information

Desired Start Date:    Salary Expectation: $

Are you legally authorized to work in the country of employment? Yes No

Employment History

Employer 1

From: To:

Employer 2

From: To:

Education

Graduation Date:

References (Professional)

Legal Disclosures

At-Will Employment: I understand and agree that if hired, my employment will be at-will and either I or the employer may terminate the employment relationship at any time, with or without cause or notice, unless a separate written agreement signed by an authorized representative of the employer specifies otherwise.

Equal Employment Opportunity: The employer provides equal employment opportunity without regard to race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable law. Employment decisions are based on qualifications, merit and business need.

Investigation, Consent & Authorization

I hereby authorize the employer, its agents and/or representatives to conduct background investigations, consumer reports, criminal history checks, motor vehicle record searches (where job-related), drug and alcohol testing, and verification of my education, employment history and other credentials as necessary to evaluate my qualifications for employment. I understand that such inquiries may include the procurement of information from public and private sources.

I authorize all persons, schools, companies, law enforcement agencies and courts to release any information concerning my background to the employer, and I release such parties from liability for doing so. I further release the employer from liability for obtaining and using such information in its hiring decision consistent with applicable law.

Conviction Disclosure: Have you ever been convicted of a crime, excluding minor traffic offenses? Yes No

Applicant Certification and Authorization

I certify that all information provided on this form and in any accompanying documents is true, complete, and correct to the best of my knowledge. I understand that any misrepresentation, falsification or omission of information may result in rejection of my application or, if employed, discipline up to and including termination.

I acknowledge that any offer of employment may be conditioned upon successful completion of the background checks and any required examinations or screenings. I agree to cooperate in the completion of these processes and to provide additional information or documentation as requested.

I authorize the release of employment-related information by prior employers and educational institutions to the employer for purposes of verification. I understand that the employer may retain a copy of this authorization.

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