Application for Employment - Helping Hands Hawaii



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Application for Employment

INSTRUCTIONS: Please complete all portions of this application to be considered for employment. If you require accommodation during the employment application process, including assistance in the completion of this employment application, please let us know. Helping Hands Hawaii is an equal opportunity employer. Helping Hands Hawaii does not discriminate on the basis of age, race, sex, religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category recognized by state and federal laws. This employment application is valid for a three month period after submission to the Agency and only for the desired position.

PERSONAL INFORMATION

|Name:       Social Security No.:       |

|Address:       City:       State:       |

|Zip Code:       |

|Home Phone:       Cell Phone:       Email Address:       |

|Can you, after employment, submit verification of your legal right to work in the United States? |

|Yes No |

DESIRED EMPLOYMENT Please check: Full-Time Part-Time

|Desired position:       Date Available to Start:       Desired Salary:       |

|Availability: |

|Have you ever applied for employment at this company? Yes No |

| If yes, when did you apply and for what position? |

|Have you ever worked for this company before? Yes No |

| If yes, what were your dates of employment and position held?       |

|Referral Source: Helping Hands Hawaii website HireNet Hawaii |

| |

|Craigslist Employment Agency |

| |

|Hawaii Job Engine Employee, please specify:       |

| |

|JEMS Other, please specify:       |

EDUCATION

|School level |Name and location of school |Number of years |Did you graduate? |Type of degree attained |

| | |attended | | |

|High school |      |      |      |      |

|College |      |      |      |      |

|Other |      |      |      |      |

|Do you intend to go back to school? Yes No |

EMPLOYMENT RECORD

List your last four employers, starting with the most recent. For each employer, you must answer all questions. Attach additional sheets if necessary, following the same format.

|Name of Employer:       Employer’s Phone Number:       |

|Street Address:       City, State, Zip Code:       |

|Date Started:       |Date Ended:       |

|Starting Rate of Pay:       |Ending Rate of Pay:       |

|Job Title:       Immediate Supervisor’s Name and Title:       |

|Description of Work:       |

|Reason for Leaving:       |

|May we contact your supervisor? Yes No |

|Name of Employer:       Employer’s Phone Number:       |

|Street Address:       City, State, Zip Code:       |

|Date Started:       |Date Ended:       |

|Starting Rate of Pay:       |Ending Rate of Pay:       |

|Job Title:       Immediate Supervisor’s Name and Title:       |

|Description of Work:       |

|Reason for Leaving:       |

|May we contact your supervisor? Yes No |

|Name of Employer:       Employer’s Phone Number:       |

|Street Address:       City, State, Zip Code:       |

|Date Started:       |Date Ended:       |

|Starting Rate of Pay:       |Ending Rate of Pay:       |

|Job Title:       Immediate Supervisor’s Name and Title:       |

|Description of Work:       |

|Reason for Leaving:       |

|May we contact your supervisor? Yes No |

EMPLOYMENT RECORD, CONTINUED

|Name of Employer:       Employer’s Phone Number:       |

|Street Address:       City, State, Zip Code:       |

|Date Started:       |Date Ended:       |

|Starting Rate of Pay:       |Ending Rate of Pay:       |

|Job Title:       Immediate Supervisor’s Name and Title:       |

|Description of Work:       |

|Reason for Leaving:       |

|May we contact your supervisor? Yes No |

PROFESSIONAL REFERENCES

Please provide the names of three persons you are not related to, whom you have known professionally for at least one year, and whom we can contact.

|Name |Address |Relationship |Years Known |Phone Number |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

JOB SKILLS, QUALIFICATIONS, AND EMPLOYMENT GAPS

Please summarize your job skills, training and/or study that are relevant to the desired position. In addition, explain any periods that you were not working. Attach additional sheets if necessary.

|      |

| |

| |

CERTIFICATION

PLEASE READ CAREFULLY

A. I certify that the information contained in this application is true and correct. I understand that any false or misleading statements or omissions regarding this application, whenever discovered, are grounds for disqualification from further consideration or for dismissal from employment.

B. If employed, I agree to conform to the guidelines and policies of the Company. I understand that MY EMPLOYMENT IS AT-WILL AND CAN BE TERMINATED AT ANY TIME AND FOR ANY REASON WITH OR WITHOUT ADVANCE NOTICE.

C. I understand and agree that only the President of the Company has any authority to enter into any agreement to employ me for any specified period of time or to modify terms and conditions of my employment. I agree that such an agreement must be in writing and signed by the President, and I will not rely upon anything else.

D. I understand and agree that the Company may make a full and complete investigation of my personal or employment history, and authorize any former employer, person, firm, corporation, school, government agency, or other entity to provide the Company with any information (including fact or opinion) they may have regarding me. I understand that this application is not complete unless and until all background checks and references have been investigated to the Company’s satisfaction. I understand and agree that if offered employment by the Company, any such employment offer shall be dependent upon the receipt of satisfactory references as determined by the Company. If employed by the Company, I further authorize the Company to provide truthful information (including fact or opinion) regarding my employment to any potential or future employer and release and waive any claims against the Company for truthfully communicating any such information to a potential or future employer.

E. I understand and agree that I may be required to submit to drug testing and a complete post-offer medical examination as part of my application for employment. I also understand and agree that I may be required to submit to a complete medical examination during my employment with the Company, provided that such examination is job-related and consistent with business necessity. The Company will pay the cost of such an examination. I authorize the physician conducting the examination and any laboratory testing any specimen obtained by the physician or collection site to disclose the results of the examination and the laboratory test to the Company in accordance with state and/or federal laws. The Company will keep such results confidential and disclose the results only to persons who need to know or where required by law. Also, I agree to fully cooperate and provide the Company with any additional consent(s) and/or release(s) as required by the Company to investigate my employment application. FOR MORE DETAILED INFORMATION, PLEASE CONSULT OUR DRUG TESTING POLICY CONTAINED IN OUR EMPLOYEE HANDBOOK.

F. The Company may inquire into and consider any criminal conviction record that I may have after it makes a conditional offer of employment. The Company may withdraw a conditional employment offer if I have a criminal conviction record which bears a rational relationship to the duties and responsibilities of the position for which I am applying. Any criminal conviction record that is more than 10 years old or that involves certain Family Court matters will not be considered.

G. I understand and agree that all of the foregoing terms and conditions will become part of my employment relationship with the Company if the Company employs me.

Authorization/Signature of applicant:

Signature: ___________________________________ Date: _____________________

ARBITRATION AGREEMENT

In consideration for the Company’s examination and investigation of my employment application and in order to promptly resolve any legal dispute I may have with the Company regarding my recruitment, employment, employment benefits or separation of employment (including but not limited to any claim of employment discrimination under the federal Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, the American with Disabilities Act, any claim relating to an employee benefit plan under the Employee Retirement Income Security Act, or any claim under Hawaii law), I agree to submit any and all such claims to final and binding arbitration pursuant to the Federal Arbitration Act. The parties agree to waive any right to a trial by jury but understand that the arbitrator has the authority to award damages, costs and fees pursuant to applicable laws.

Signature: ______________________________ Date: ___________________

Please continue to the next page for the Voluntary Self-Identification form.

2100 N. Nimitz Highway ( Honolulu, HI 96819 ( Email: jobs@ ( Fax: (808) 440-3849

VOLUNTARY SELF-IDENTIFICATION FORM

As an equal opportunity employer and government contractor, we are obligated by Federal regulations to monitor our employment practices to ensure nondiscrimination, measure the effectiveness of our affirmative action program and produce required reports. To assist in this process, you are invited to complete this questionnaire.

You are not required by law to provide the information requested. If you elect to provide the data, it will be detached from your application and kept confidential. This information will only be used in accordance with government regulations and Affirmative Action policy. Refusal to provide this data will not adversely affect consideration for employment.

DECLINE TO STATE

RACE/ETHNIC GROUP: Please check all that are applicable.

HISPANIC OR LATINO

WHITE

ASIAN

BLACK/AFRICAN AMERICAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

AMERICAN INDIAN OR ALASKA NATIVE

GENDER: Female Male

VETERAN STATUS

Disabled Veteran: a veteran who a) is entitled to compensation (or who, but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs Administration, or b) was discharged or released from active duty because of a service-connected disability.

Armed Forces Services Medal Veteran: any veteran who, while serving on active duty in the Armed Forces, participated in a US military operation for which a service medal was awarded pursuant to Executive Order 12985.

Recently Separated Veteran: any veteran during the three year period beginning on the date of such veteran’s discharge or release from active duty.

Other Protected Veteran: a person who served on active duty during a war or in a campaign or expedition for which a campaign badge was authorized.

APPLICANT’S NAME (please print) __     _________________________________________

Signature _______________________________________ Date ____________________

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

Page 1 of 8

|Why are you being asked to complete this form? |

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.[i] To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

|How do I know if I have a disability? |

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

|Blindness |Autism |Bipolar disorder |Post-traumatic stress disorder (PTSD) |

|Deafness |Cerebral palsy |Major depression |Obsessive compulsive disorder |

|Cancer |HIV/AIDS |Multiple sclerosis (MS) |Impairments requiring the use of a wheelchair |

|Diabetes |Schizophrenia |Missing limbs or partially |Intellectual disability (previously called mental |

|Epilepsy |Muscular dystrophy |missing limbs |retardation) |

| | | | |

Please check one of the boxes below:

| |YES, I HAVE A DISABILITY (or previously had a disability) |

| |NO, I DON’T HAVE A DISABILITY |

| |I DON’T WISH TO ANSWER |

__________________________ __________________

Your Name Today’s Date

Voluntary Self-Identification of Disability

Form CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

Page 2 of 8

| Reasonable Accommodation Notice |

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

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[i] Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

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