Personal History Form

PERSONAL HISTORY FORM

Purpose: This Personal History Form is used to collect factual background information to determine eligibility for consideration. Completion of this form does not guarantee selection, employment, or other benefit. Provide complete and accurate information. Omissions, false statements, or material misrepresentations may be grounds for disqualification or termination.

SECTION 1 — Personal Information

Date of Birth:    Place of Birth (City, State/Country):

Phone:    Email:

Social Security Number:    Driver's License/ID #:

SECTION 2 — Citizenship & Eligibility

Citizenship Status: United States Citizen Permanent Resident Other

Are you legally authorized to work in this jurisdiction?   Yes   No

SECTION 3 — Emergency Contact

Relationship:    Phone:

SECTION 4 — Education

SECTION 5 — Employment History (Most Recent First)

Position / Title:    Supervisor:

Start Date:    End Date:    Phone:

Position / Title:    Supervisor:

Start Date:    End Date:    Phone:

Position / Title:    Supervisor:

Start Date:    End Date:    Phone:

SECTION 6 — Military Service

Have you served in the military?   Yes   No

SECTION 7 — Criminal History

Have you ever been convicted of a felony or misdemeanor? (Exclude minor traffic offenses unless DUI-related.)   Yes   No

SECTION 8 — References

Relationship:    Phone:

Relationship:    Phone:

SECTION 9 — Additional Information

AUTHORIZATION, CERTIFICATION & PRIVACY NOTICE

Authorization: I hereby authorize the verification of all statements contained in this form and any accompanying documents. I authorize former employers, schools, references, and other persons to provide any information regarding my employment, education, or other background, and I release those parties from any liability for providing such information in good faith.

Certification: I certify that the information provided on this Personal History Form is true, complete, and correct to the best of my knowledge. I understand that any willful misstatement, omission, or falsification of facts may result in denial of consideration or revocation of any offer or termination of relationship.

Privacy: Personal information collected on this form will be used for background review, recordkeeping, and related administrative purposes. Access to this information is limited to authorized personnel and will be handled in accordance with applicable privacy laws.

Consent to Background Check: I understand that a background investigation, which may include criminal history, employment verification, education verification, and other public records checks, may be conducted. I consent to such investigations and understand that adverse information may be considered in the evaluation process.

I authorize the verification and background checks described above and certify the accuracy of the information provided.

WARNING: Knowingly making a false statement on this form may be punishable under applicable law and may result in refusal of consideration or termination.

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