Scsform-0410ehbvl - Employment History Background Verification Log - Los Angeles World Airports Security Credential Section

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10-Year Employment History Background Log
LOS ANGELES WORLD AIRPORTS SECURITY CREDENTIAL SECTION
EMPLOYMENT HISTORY BACKGROUND VERIFICATION LOG
NEW HIRE
EMPLOYEE (CURRENT)
APPLICANT NAME:
SOCIAL
DOB:
AUTHORIZED SIGNER:
EMAIL:
Page______
(MM / DD / YYYY)
SECURITY #:
(XXX – XX – XXXX)
of ______
ALIAS / NICKNAME:
ORGANIZATION NAME
ORGANIZATION CODE:
(APPLICANT ONLY)
(COMPANY ONLY )
SECURITY CREDENTIAL SECTION
Dates of
Full name, title, &
Full name, title, and
Date and time
Name & address of each
Method of verification
employment,
telephone number of
telephone number of
information was
employer / school or if
(telephone, fax, letter,
Re-verification
education, or
person contacted to
person conducting
unemployed for 12 months
verified –
etc) NOTE: Supporting
Comments (Badge Office
unemployment
verify employment,
background verification
or more note the
documents must be
use only)
indicate YES or
(list most recent
school or
(if not the same as the
circumstances
attached
NO
first)
unemployment
authorized signer)
FROM: (MM / YYYYY)
YES
NO
NAME:
NAME:
/
Email
Fax
TITLE:
TITLE:
DATE:
Phone
Other
TO: PRESENT
PHONE:
PHONE:
Official Letter
TIME:
EMAIL:
EMAIL:
Official Document
YES
NO
NAME:
NAME:
/
Email
Fax
FROM: (MM / YYYYY)
TITLE:
TITLE:
Phone
Other
DATE:
TO:
PHONE:
PHONE:
Official Letter
TIME:
EMAIL:
EMAIL:
Official Document
YES
NO
NAME:
NAME:
/
Email
Fax
FROM: (MM / YYYYY)
TITLE:
TITLE:
Phone
Other
DATE:
TO:
PHONE:
PHONE:
Official Letter
TIME:
EMAIL:
EMAIL:
Official Document
YES
NO
NAME:
NAME:
/
Email
Fax
FROM: (MM / YYYYY)
TITLE:
TITLE:
Phone
Other
DATE:
TO:
PHONE:
PHONE:
Official Letter
TIME:
EMAIL:
EMAIL:
Official Document
*IF ADDITIONAL SPACE IS NEEDED, PLEASE MAKE COPIES OF THIS FORM. ATTACH THE EMPLOYEE BACKGROUND INVESTIGATION LOG(S), ALL INVESTIGATION AND VERIFICATION DOCUMENTATION, AND SIDA TRAINING INFORMATION TO THE EMPLOYMENT APPLICATION FOR COMPANY’S FILE.
Authorized Signer Name
Authorized Signer Code
Contact by: Phone / Fax / Email
Date / Time Completed
SCS Employee Re-verifying Information
Date Re-Verification Completed
Supervisor Approving
Date / Time Approved
SCSFORM:0410EHBVL
REVISED 01/20/2011

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