Ban The Box Complaint Form

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First Name

Last Name

Address

City

State

ZIP Code

Phone

Prospective Employer

Prospective Employer Address

Prospective Employer City

Prospective Employer ST

Prospective Employer ZIP Code

Prospective Employer Contact Name

Prospective Employer Contact Phone

15 Or More Employees

Does the Employer have 15 or more employees in the current or preceding calendar year?

Position Applied For

Disclosure Before Interview

Have you been asked to disclose your criminal record or criminal history before being notified that you were selected for an interview?

Disclosure Before Conditional Offer

Have you been asked to disclose your criminal record or criminal history before a conditional offer of employment?

Bond Required

Is a bond required for the position applied for?

EMS Systems License

Does the position applied for require a license under the Emergency Medical Services Systems Act?

Accept and Submit

BY ACCEPTING AND SUBMITTING THIS FORM, THE COMPLAINANT AFFIRMS AND CERTIFIES THAT ALL INFORMATION PROVIDED AND THE STATEMENTS MADE HEREIN ARE TRUE, CORRECT, AND COMPLETE.

Ban The Box Complaint Form

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Ban The Box Complaint Form

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