Verification of EmploymentThank you for taking the time to fill out a Verification of Employment form. Please provide your information and role within your organization Your Name * First Name Last Name Organization Name * Your Email * Position/Title * Organization's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Former Employee Verification of Employment Former Employee Name * First Name Last Name Position * Beginning Date of Employment * MM DD YYYY Ending Date of Employment * MM DD YYYY Average Number of Hours Worked per Day * Average Number of Days Worked per Week * Full Time or Part Time? Full Time Part Time Contracted Unsupervised access to children * Has the employee ever been under investigation for, or has been found to have violated, any state or federal statute relating to child abuse or neglect, sexual misconduct or any sexual offense, including those offenses prohibited in Chapter 30, Article 3, 3A, 4, 6, 6A, 9, 37, 37A or 52 NMSA 1978, unless the allegations were false or unsubstantiated. Yes No If "Yes" Selected above please describe Ethics * Has the employee ever been under investigation for, or found to have violated, any ethical rule or policy approved by a former employer that previously employed the applicant, unless the allegations were false or unsubstantiated? Yes No If "Yes" Selected above please describe Revocation of Certificate * Has the employee ever had a professional license or certificate denied, suspended, surrendered or revoked due to a finding of child abuse or ethical misconduct or while allegations of child/adult abuse or ethical misconduct were pending or under investigation? Yes No If "Yes" Selected above please describe Please note, that by submitting this Verification of Employment Form, it serves as authorization for the disclosure of information requested releasing the applicant's previous employers from any liability related to the disclosure or release of records. Thank you!
