initials_ Investigator’s Yes No 8. Have you ever resigned while under investigation by your internal affairs, loss prevention employer’s or any other disciplinary investigation unit? Date resigned: / Name of employer: Month Year: Yes No 9. Have you ever left an employer and been told you were not eligible for rehire? Date: / Name of employer: Month Year Yes No 10. Have you ever received a written reprimand from any employer? Date: / Name of employer: Month Year Yes No 11. Have you ever received counseling or otherwise been put on notice by any employer? Year Name of employer: / Month Date: Yes No 12. Has any employer ever suspended you for misconduct or as a disciplinary action? Year Name of employer: / Month Date: Yes No 13. Did you ever steal anything of value from your employer? (Other than paper clips, etc) Name of employer: Date of theft: / Month Year
Investigator’s initials_ Yes No 8. Have you ever resigned while under investigation by your employer’s internal affairs, loss prevention or any other disciplinary investigation unit? Name of employer: Date resigned: / Month Year: Yes No 9. Have you ever left an employer and been told you were not eligible for rehire? Name of employer: Date: / Month Year Yes No 10. Have you ever received a written reprimand from any employer? Name of employer: Date: / Month Year Yes No 11. Have you ever received counseling or otherwise been put on notice by any employer? Name of employer: Date: / Month Year Yes No 12. Has any employer ever suspended you for misconduct or as a disciplinary action? Name of employer: Date: / Month Year Yes No 13. Did you ever steal anything of value from your employer? (Other than paper clips, etc) Name of employer: Date of theft: / Month Year