Ban The Box Complaint Form

First Name

Last Name

Address

City

State

IL AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

ZIP Code

Phone

Email

Prospective Employer

Prospective Employer Address

Prospective Employer City

Prospective Employer ST

IL AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Prospective Employer ZIP Code

Prospective Employer Contact Name

Prospective Employer Contact Phone

15 Or More Employees

Yes No

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

Position Applied For

Disclosure Before Interview

Yes No

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

Yes No

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

Bond Required

Yes No Unknown

Is a bond required for the position applied for?

EMS Systems License

Yes No Unknown

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

Accept and Submit

Yes No

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.

Submit

Reset