HR Security Prescreen Form

HR SECURITY PRESCREEN FORM

Applicant Information

Citizenship/Immigration Status: U.S. Citizen Permanent Resident Other:

Position Information

Security & Background Information

Have you ever held a government or industry security clearance? Yes No

If yes, clearance type and granting authority: Date granted/expired:

Have you ever been denied a security clearance, had a clearance suspended or revoked, or withdrawn an application? Yes No

Have you ever been convicted of a felony, pled guilty or no contest to a felony, or are you currently charged with a felony? Yes No

Have you used illegal drugs or abused prescription drugs within the past five years? Yes No

Do you have close personal or financial ties to foreign nationals or foreign governments that could present a security concern? Yes No

Have you traveled or resided outside the country in the past seven years for business, education, or personal reasons? Yes No

Employment History (Most recent first)

Education

Professional References

Legal Disclosures & Authorizations

At-Will Employment: I understand and acknowledge that, unless expressly provided otherwise in a signed written agreement, my employment is at-will and may be terminated by me or the employer at any time, with or without cause or notice. I further acknowledge that no representative of the employer has the authority to alter this at-will relationship except by written agreement signed by an authorized officer.

Equal Opportunity: The employer provides equal employment opportunities without regard to race, color, religion, sex, age, national origin, disability, genetic information, or any other status protected by applicable law.

Authorization to Investigate: I authorize the employer and its agents to conduct a thorough pre-employment security investigation, including but not limited to verification of employment, education, credit history where job-related, criminal records, motor vehicle records, security clearance records, and fingerprinting. I authorize all persons, schools, companies, corporations, credit agencies, law enforcement agencies, and government agencies to release any information concerning my background. I release all such persons and entities from any liability arising from the release of such information.

Consent to Drug Testing and Credit Check: I consent to submit to pre-employment drug/alcohol testing and any post-offer testing required by the employer. Where job-related and permitted by law, I consent to a consumer credit check as part of the security prescreen.

False Statements and Withholding Information: I understand that failure to disclose or any misrepresentation of material facts on this form is grounds for denial of employment, withdrawal of an offer, or immediate termination if discovered after employment begins.

Data Use and Retention: I understand that information collected on this form will be used solely for employment-related screening, security adjudication, and compliance with legal requirements. Personal information will be retained and disposed of in accordance with applicable law and internal retention policies.

I authorize investigation and release of records as described above.

I consent to required drug/alcohol testing.

I understand that false statements or omissions may disqualify me from employment or lead to termination.

Additional 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 understand that this form is part of the pre-employment security screening process and that incomplete or misleading statements may result in denial of employment or revocation of any offer.

I authorize the release of any records or information that may be necessary to complete a full background investigation, including criminal history, education, employment verification, credit checks where permitted by law, and security clearance history. I release all parties from liability for providing such information in good faith.

Applicant agrees to cooperate with any requested interviews and to provide fingerprints if required for government or contractor adjudication.

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