Employment Disclosure & Service Letter Authorization Form

Employment Disclosure and Service Letter Authorization
Agency Name:
Address:
Phone:
EMPLOYEE INFORMATION
Full Name (Print):
Address:
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
1. AUTHORIZATION FOR RELEASE OF EMPLOYMENTINFORMATION
I, the undersigned, hereby authorize any current and/or former employer(s) to release any and
all information regarding my employment to the above-named agency, in accordance with
Delaware Service Letter Law requirements.
This includes, but is not limited to:
- Dates of employment
- Job title(s) and duties
- Work performance
- Reason for separation
- Any documented incidents or conduct
I release all parties from any liability related to the disclosure of this information.
Employee Initials:

2. FULL DISCLOSURE STATEMENT
I certify that all information I have provided in my employment application and during the hiring process represents a full and complete disclosure of my current and previous employment history.
I further affirm that all information provided is true, accurate, and complete to the best of my knowledge and belief.
Employee Initials:
3. LEGAL ACKNOWLEDGMENT
I understand that failure to provide full and complete disclosure of my employment history is a violation of Delaware law and may result in:
- Denial of employment
- Termination of employment
- Additional legal consequences
Employee Initials:
4. CONDITIONAL EMPLOYMENT (IF APPLICABLE)
Due to exigent circumstances, I understand that:
- My employment may be offered on a conditional basis pending receipt of required service letter(s).
- My continued employment is contingent upon the agency receiving satisfactory service letter(s).
I acknowledge and agree to these conditions.
Employee Initials:
EMPLOYEE SIGNATURE

Employment Disclosure and Service Letter Authorization