Employee List Form

EMPLOYEE LIST

Must be updated annually and at the time of any employee changes.

Please list below all individuals/employees that currently work or may be assigned to work at any location serviced for Tegrete Corporation.

Only if requested by Tegrete, please include background check and drug screening results for each individual you list below.

Facility Location: __________________________________________________ (enter the facility location serviced by the employees listed below)

Date Background

Results of

Date Drug Screen

Notes

Employee Name

Date I9

Results of Drug

Date of Birth

Check Completed

Background Check

Completed

(Last, First, Middle)

Completed

Screening

(*If requested)

(*If requested)

(*If requested)

1

2

3

4

5

6

7

8

9

10

11

The undersigned certifies that the individuals listed above are ALL of the individuals

that currently work at any location serviced for Tegrete.

Company Name

Printed Name of Signer

Title/Position

Signature

Date

.

*Tegrete hires contractors to perform services for some clients that require background checks and drug screening of all individuals working inside and outside their facilities

You should only

complete these sections if Tegrete has requested the information.