Security Clearance - Superior Court Of California - County Of Los Angeles (Alternative Dispute Resolution/adr) Page 4

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Separation from Employment under Unfavorable Circumstances
5.
While on probation or on a similar type of on-the-job trial period, were you ever
terminated, discharged, released, or did you resign? Mark the appropriate box below.
YES
NO
6.
Have you ever been terminated from any employment, or did you resign while you
were under investigation, or after being informed discipline would be taken, or under
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
misrepresented my qualifications and/or background. I understand and agree that
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.
SIGNATURE: _______________________________________
DATE: ____________
Comments: _______________________________________________
FOR HUMAN
RESOURCES
_________________________________________________________
USE ONLY
Received by: _____________________________ Date: ___________
Security Clearance (Revised October 2009)
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