Pre-Hire Employment License

PRE-HIRE EMPLOYMENT LICENSE

Applicant Name:   For Position:

Personal Information

Position Information

License / Certification Information

Is a professional license or certification required for the position?    Yes

Current license status:   Active   Suspended   Expired   Pending/Applied

Employment History (Most Recent First)

Employer 1

Employer 2

Education

Professional References

Reference 1

Reference 2

Reference 3

Legal Disclosures and Authorizations

At-Will Employment: I understand that any offer of employment is at-will, unless otherwise expressly agreed in a separate written agreement signed by an authorized representative of the employer. Either I or the employer may terminate the employment relationship at any time, with or without cause or notice, except where prohibited by law.

Equal Opportunity Employer: The employer does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, or any other characteristic protected by applicable law.

Background and Credential Verification: I authorize the employer and its agents to investigate and verify the information supplied on this form, including but not limited to verification of professional license(s), education, employment history, references, and any criminal history. I authorize past employers, educational institutions, licensing authorities, and references to release employment-related information to the employer or its agents.

Consent to Drug and Alcohol Testing: If required for the position, I consent to pre-employment and periodic drug and alcohol testing as authorized by applicable law and employer policy. I understand that a positive test, refusal, or failure to comply may disqualify me from employment.

Criminal Conviction Disclosure: Have you ever been convicted of a felony or misdemeanor (excluding minor traffic violations)?   Yes   No

Authorization to Verify License: By signing below I expressly authorize the employer to contact the issuing authority of any license or certification I claim and to obtain the status of such license or certification, including disciplinary history and current standing. I understand that verification of licensure and disciplinary status is a condition of employment for positions requiring licensure.

Applicant Certification

I certify that all information provided in this Pre-Hire Employment License application is true, complete and correct to the best of my knowledge. I understand that omission, misrepresentation, or falsification of information may disqualify me from consideration for employment or may be grounds for immediate dismissal if discovered after hire. I acknowledge that employment, if offered, may be contingent upon verification of qualifications, successful background checks, drug testing, and confirmation of licensure where required.

I release from liability any person or entity supplying information to the employer pursuant to this authorization. I acknowledge receipt of this notice and consent to the checks described above.

Administrative Use Only

Sign Now