Last Name                First Name                                     Initial                                                       Maiden Name

Address

Social Security Number                                                  Telephone Number Alternate Number

 

 

In Case of Emergency

Notify

Relationship

Address                                      City                                                         State                           Zip Code

 

Achievements that are Applicable for the Job Applied for:

Position applying for                                                                                    When can you start?   

Educational Achievements/Certifications/Licenses

Work Experience Achievements

Recent Employer                         Address                       Dates                    Salary                         Reason for Leaving     

Recent Employer                         Address                       Dates                    Salary                         Reason for Leaving     

Recent Employer                         Address                       Dates                    Salary                         Reason for Leaving     

 

 

Have you ever been arrested, charged or convicted of a misdemeanor or a felony, or had any registry listing or certification marked for abuse or negligence?  ___________  Yes  __________  No

If you answered yes, attach an additional page and explain.  Include dates, places, charges, and results.

I hereby certify that all of the above questions are fully, correctly and truthfully answered and I authorize this employer to contact my former employers, references and other sources in order to verify the facts furnished regarding my character and qualifications.  I hereby release any such employer or persons liability of any nature on account of furnishing such information.  I understand that any misleading, incorrect or untruthful statements may render this application void, and if I am employed, would be just cause for my termination of my employment.

 

Date                                                                              Signature

 

                                                                                   

 

RELEASE:  Having made application for employment with HMC and desiring them to be informed as to my previous record and character, I hereby authorize HMC to investigate my past record and to ascertain any and all information which may concern my record and character, whether same is of record or not, and hereby authorize my past and present employers, references, educational institutions and all persons whomsoever may have relevant information to release such information to HMC.  Further, I release my present and past employers, references, educational institutions and all persons whomsoever from any damage or liability because of furnishing said information.

 

 

References:

Dates of Employment:                 ________________________________________________________

 

Job Title:                                    ________________________________________________________

 

Reason for Termination:              ________________________________________________________

 

Eligible for rehire:                        ________ Yes  _______ No

 

Please evaluate the applicant’s performance in each of the following categories:

 

                                         Excellent                              Good                   Average                      Poor

Quality of Work                 _______                             ________            ________                  ________

Quantity of Work               _______                             ________            ________                  ________

Initiative                             _______                             ________            ________                  ________

Leadership

Attendance                        _______                             ________            ________                  ________

Ability to Get Along        _______                                ________            ________                  ________

with others

Response to                      _______                              ________            ________                  ________

Supervision                                                                  

 

Signature & Title                                                                                       Date