Investigator’s initials Spouse, fiancée or significant other (first name, last name) Spouse’s maiden name Date of marriage Month / Year Current address of spouse, fiancée or significant other if not living with you. Write “SAME” if address is the same as yours. ( Area code ) Best time to call: Daytime Evening Complete the first section below to provide information if you were raised by someone other than your parents or step parents. If you were raised by your parents or step parents, place “N/A” in the first block below and proceed to “Father’s Name.” Print clearly and use black ink only Person’s name (first name, middle initial, last name) Relationship to you (aunt, uncle, etc.) Deceased Current Residence Address Contact number ( ) Area code Best time to call: Daytime Evening Father’s name (first name, middle initial, last name) Date of birth Deceased Month / Day / Year Current Residence Address Contact number ( Area code ) Best time to call: Daytime Evening Mother’s name (first name, middle initial, last name) Date of birth Deceased Month / Day / Year Current Residence Address Contact number ( Area code ) Best time to call: Daytime Evening Step-Father’s name (first name, middle initial, last name) Date of birth Deceased Month / Day / Year Current Residence Address Contact number ( Area code ) Best time to call: Daytime Evening Step-Mother’s name (first name, middle initial, last name) Date of birth Deceased Month / Day / Year Current Residence Address Contact number ( Area code ) Best time to call: Daytime Evening
Print clearly and use black ink only 4th former employer or period of unemployment Investigator’s initials Name of former employer Former employer’s mailing address Start Date Month / Year End Date Month / Year Full time Part-Time Temporary Military Self-Employed Volunteer Internship Unemployed Former employer’s telephone number for employment verification (Personnel) Your title or position Telephone number ( Area code ) Reason for leaving employment Resigned to take better position Lay off Contract expired Return to school Terminated (fired) Completion of military service Resigned to avoid being terminated Resigned while under investigation Quit without giving notice as required by company policy Reason not listed, explain below Explain reason for leaving employment; continue on page twenty-nine (29) if necessary Do you feel this former employer would rehire you? If you answered “No” explain below; continue on page twenty-nine (29) if necessary. Yes No Supervisor’s name (first name, last name) Supervisor’s title Telephone number where your former supervisor may be reached and time available to take calls Telephone number ( Area code ) (work or cell phone) Best time to call: Daytime Evening Did you ever received or do you have any pending disciplinary actions? Explain below; continue on twenty-nine (29) if necessary. Yes No Co-worker’s name: (first name, last name) Telephone number where co-worker can be reached ( ) Area code (home or cell phone) Best time to call: Daytime Evening Investigator’s initials
Investigator’s initials_ Yes No 8. Have you ever resigned while under investigation by your employer’s internal affairs, loss prevention or any other disciplinary investigation unit? Name of employer: Date resigned: / Month Year: Yes No 9. Have you ever left an employer and been told you were not eligible for rehire? Name of employer: Date: / Month Year Yes No 10. Have you ever received a written reprimand from any employer? Name of employer: Date: / Month Year Yes No 11. Have you ever received counseling or otherwise been put on notice by any employer? Name of employer: Date: / Month Year Yes No 12. Has any employer ever suspended you for misconduct or as a disciplinary action? Name of employer: Date: / Month Year Yes No 13. Did you ever steal anything of value from your employer? (Other than paper clips, etc) Name of employer: Date of theft: / Month Year