Basic Informtion
Gender
Position Applied for
Are you a citizen of the United States?
If no, are you authorized to work in the U.S.?
Are you currently working in a NID-HCA branch office?
Have you ever been convicted of a felony?
High School: Did you graduate?
College: Did you graduate?
Other Education: Did you graduate?


Refrences
Refrence 1 Relationship
Refrence 1 Phone
Refrence 2 Relationship
Refrence 2 Phone
Refrence 3 Relationship
Refrence 3 Phone


Previous Emplyment
Phone
Supervisor
Starting Salary
Ending Salary
From
To
May we contact your previous supervisor for a reference?

Phone
Supervisor
Starting Salary
Ending Salary
From
To
May w e contact your previous supervisor for a reference?

Phone
Supervisor
Starting Salary
Ending Salary
From
To
May w e contact your previous supervisor for a reference?


Licenses
Issuing Agency
Expiration Date
Issuing Agency
Expiration Date
Issuing Agency
Expiration Date


Certifications
Certifying Agency
Date of License
Certifying Agency
Date of License
Certifying Agency
Date of License


Background Check Authorization

AUTHORIZATION TO OBTAIN INFORMATION from LAW ENFORCEMENT AGENCIES I, the below signed, authorize NID-Housing Counseling Agency to obtain all information in your possession to the NID Housing Counseling Agency regarding any convictions I may have for felony offenses

This information is to be used only to determine my fitness to serve as a Certified Housing Counselor and this authorization is valid throughout the application process and certification period.




Disclaimer and Signature

I being duly sworn, do hereby state under penalty of perjury that (i) I have read and prepared the foregoing application and attached appendices, and have made or approved all statements, representations and covenants therein or in connection therewith and have answered each question therein full and frankly and without concealment or reservation, and such answers are true and complete; (ii) I understand that NID-HCA will rely upon such statements, representations and answers in making its decision regarding my certification.




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