Pre-Employment Background Check — TandT LLC | City of Cincinnati Engagement

1

Personal Information

Legal First Name *

Middle Name

Legal Last Name *

Other Names Used

Maiden / Former Name

Any Other Names Used

Date of Birth & Identification

Date of Birth *

Social Security Number *For identity verification only

Driver's License / State ID No.

ID Issuing State

ID Expiration Date

Citizenship / Work Authorization *

2

Contact & Address Information

Current Address

Street Address *

City *

State *

ZIP Code *

Years at Address

Previous Address (if less than 5 years at current)

Previous Street Address

City

State

Contact Details

Primary Phone *

Secondary Phone

Email Address *

3

Position & W2 Employment Details

✓ W2 Employee — Employed by TandT LLC

Position / Job Title Applied For *

Client Engagement / Contract *

Department / Division

Anticipated Start Date

Work Location

Employment Schedule *

Compensation Type *

Salaried Hourly

4

Employment History (Last 10 Years)

List all employers for the past 10 years, starting with the most recent.

Employer 1 — Most Recent

Company Name *

Your Job Title *

Start Date *

End Date

Supervisor Name

Supervisor Phone

Reason for Leaving

Employer 2

Company Name

Your Job Title

Start Date

End Date

Supervisor Name

Supervisor Phone

Reason for Leaving

Employer 3

Company Name

Your Job Title

Start Date

End Date

Reason for Leaving

5

Education & Credentials

Highest Education Level *

Field of Study / Major

Institution Name

Graduation Year

Professional Licenses / Certifications

6

Professional References (Minimum 3 Required)

Provide at least 3 professional references who can attest to your work character and performance. Do not list family members.

Reference 1 — Required

Full Name *

Relationship *

Company / Organization

Phone Number *

Email Address

Years Known

Reference 2 — Required

Full Name *

Relationship *

Company / Organization

Phone Number *

Email Address

Years Known

Reference 3 — Required

Full Name *

Relationship *

Company / Organization

Phone Number *

Email Address

Years Known

7

Background Disclosures

Answer all questions truthfully. A "Yes" answer does not automatically disqualify you — each case is reviewed individually by TandT LLC. Failure to disclose may result in disqualification.

Have you ever been convicted of, pled guilty to, or pled no-contest to a felony? *

No Yes

If yes, please explain (charge, date, jurisdiction)

Have you ever been convicted of a misdemeanor (excluding minor traffic violations)? *

No Yes

If yes, please explain

Are there any pending criminal charges against you? *

No Yes

Have you ever been terminated or asked to resign from any position? *

No Yes

If yes, please explain

Have you ever been subject to a civil judgment, restraining order, or professional disciplinary action? *

No Yes

8

Authorization & Consent

Background Check Authorization & Release — TandT LLC

I hereby authorize TandT LLC, its agents, and designated third-party screening providers to conduct a thorough background investigation in connection with my W2 employment application supporting the City of Cincinnati State Contract engagement. This investigation may include, but is not limited to: criminal history (federal, state, and county), sex offender registry, employment verification, education verification, professional license verification, credit history (where legally permissible and job-related), driving records, civil court records, and personal and professional references.

I release from liability TandT LLC and all persons and organizations providing information pursuant to this authorization. I understand that a consumer report may be obtained and that I have the right to request disclosure of the nature and scope of any such report under the Fair Credit Reporting Act (FCRA). I acknowledge that this authorization shall remain valid for the duration of my W2 employment with TandT LLC, and I consent to additional checks as required by client contract obligations.

I certify that all information provided in this form is true and accurate to the best of my knowledge. I understand that any misrepresentation, falsification, or material omission may result in immediate disqualification or termination of employment with TandT LLC.

I authorize TandT LLC to conduct the background check as described above * I authorize TandT LLC to contact my listed professional references * I authorize verification of my employment and education history * I certify that all information provided in this form is true and accurate *

Printed Full Name *

Today's Date *

Signature * (draw in the box below)

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