CC Form 29A
ev. 4/2012
Title of Position HireNet Job Order No.
Name: __________________________________________________________________________________________
Last Name First Name M.I.
Home Address: ___________________________________________________________________________________
Street City State Zip
Mailing Address: __________________________________________________________________________________
Street City State Zip
Telephone: ( ) ___________________________________ ( ) _____________________________________
Home Other
Email Address: ____________________________________________________________________________________
Non-Discrimination and Affirmative Action Information: The University of Hawai‘i is an equal opportunity/ affirmative action
institution and is committed to a policy of nondiscrimination on the basis of race, sex, age, religion, color, national origin, ancestry,
disability, marital status, sexual orientation, gender identity and expression, victims of domestic or sexual violence, genetic information,
status as a protected veteran, National Guard participation, breastfeeding, and arrest/court record (except as permissible under State
CLERY ACT: In accordance with the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, annual
campus crime statistics for the University of Hawai‘i may be viewed at:, or a paper copy may be obtained
upon request from the respective UH Campus Security or Administrative Services Office.
List in reverse chronological order all schools you attended beyond Grade 12:
School Name/Address Major Field of Study Degree Date Degree Obtained
List in reverse chronological order all relevant military (if appropriate), trade, technical, apprenticeship, or
special training you have received:
(Please include dates of all training)
Licenses/Certifications/Specific Skills: (Please indicate type, registration number and the
state or other licensing authority.)
II. TEACHING EXPERIENCE (Begin with your present or most recent teaching experience)
School Name/Address Position Title Date(s)
Course(s) Taught:
III. WORK EXPERIENCE (Starting with the present or most recent employer. Add pages, if necessary)
Position Title:
Dates: FT/PT (%):
Description of Duties:
Position Title:
Dates: FT/PT (%):
Description of Duties:
Position Title:
Dates: FT/PT (%):
Description of Duties:
IV. CURRENT REFERENCES (List names of those who may be contacted regarding your application.)
Name Mailing Address Telephone Number Email Address
I hereby certify that all statements in this application are true and correct to the best of my knowledge. I further
agree and understand that information contained in this application may be verified and that any misstatements
of material facts herein may cause forfeiture of all rights to any employment with the University of Hawai‘i
Community Colleges. I also understand that, if selected, I must present documentary evidence to verify my
employment eligibility, pursuant to the Immigration Reform and Control Act of 1986.
Date: _________________________ Original Signature of Applicant: ______________________________________