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Last name First name Initial Maiden name

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Address

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Social security number Telephone number

In case of emergency

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Notify

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Relationship Telephone number

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Address City State Zip code

Achievements that are Applicable to the Job Applied For

Position applying for When can you start?

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Educational Achievements/Certificates/Licenses

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Work experience achievements

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Recent Employer Address Dates Salary Reason for leaving

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Recent Employer Address Dates Salary Reason for leaving

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Recent Employer Address Dates Salary Reason for leaving

Have you ever been arrested, charged or convicted of a misdemeanor or 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 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.

Signature__________________________________ Date______________________

__________________________________________________________________________

Reference: _______________________________________

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