HR Region Manager Form

HR REGION MANAGER FORM

Position Information

Position Applied For:   Department:

Reporting Manager (if known):   Desired Start Date:

Full-Time    Part-Time    Exempt    Non-Exempt    Contract / Consultant

Personal Information

Date of Birth:   SSN Last 4 (for background check reference only):

Employment History (Most Recent First)

Employer 1

Employer 2

Education & Professional Development

Professional References

Reference 1

Reference 2

Reference 3

Legal Disclosures and Authorizations

At-Will Employment Statement: I understand that the completion of this form does not constitute an employment contract. If employed, I acknowledge that employment is at-will and may be terminated by either party at any time, with or without cause or notice, unless a separate written agreement signed by an authorized company representative states otherwise.

Equal Employment Opportunity: The organization does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, or any other characteristic protected by applicable law. Applicants will be considered based on qualifications and business needs.

False Statements: I certify that all information I have provided in this form is true, correct, and complete. I understand that any false, omitted, or misleading statement may result in denial of employment or immediate termination of employment if discovered after hire.

By checking the box below, I authorize the employer and its agents to contact my former employers, educational institutions, references, and relevant third parties to verify any information provided and to obtain background and consumer reports, including criminal history, motor vehicle records (if relevant), and credit information where permitted by law.

I authorize verification and background checks as described above.

Have you ever been convicted of a felony or misdemeanor that has not been annulled, sealed, expunged, or statutorily eradicated?    Yes    No

Applicant Certification

I certify that the information contained in this form and any accompanying documents is true and complete to the best of my knowledge. I understand that misrepresentation or omission of material facts may be grounds for refusal of employment or, if employed, termination. I authorize the employer to rely on this certification in determining my eligibility for employment.

Applicant Affirmation: I certify the above statements and authorize the release of information as indicated.

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