Separation from Employment under Unfavorable Circumstances
While on probation or on a similar type of on-the-job trial period, were you ever
5.
terminated, discharged, released, or did you resign? Mark the appropriate box below.
YES
NO
employment, or did you resign while you
Have you ever been terminated from any
6.
rmed discipline would be taken, or under
were under investigation, or after being info
any other unfavorable circumstances? Mark the appropriate box below.
YES
NO
If the response to Question 5 and/or 6 is "Yes", provide the requested information
below (attach additional sheets if necessary using the same format).
Date
Employer
Reason for Discharge/Resignation and/or
Failure of Probation
I certify that the above information is true and correct and that I have not
background. I understand and agree that
misrepresented my qualifications and/or
any false statement or omission of a material fact will cause forfeiture of all rights to
employment or participation as a contractor
or volunteer with the Superior Court of
California, County of Los Angeles.
________________
DATE: ____________
SIGNATURE: _______________________
Comments: _______________________________________________
FOR HUMAN
RESOURCES
_________________________________________________________
USE ONLY
Received by: _____________________________ Date: ___________
Security Clearance (Revised April 2007)
Page 3 of 3