Employment Application - Manoa Cottage

Manoa Cottage Application for Employment

Equal Employment Employer: Manoa Cottage is an equal opportunity employer. Applications are considered for positions without discriminating on the basis of race, color, religion, national origin, ancestry, sex (including gender and gender identity or expression), sexual orientation, age, disability, genetic information, marital status, arrest or court record, credit history, domestic or sexual violence victim status, veteran/military status, citizenship status, or any other characteristic protected by federal, state, or local law.

Position Applying for: *

Salary Desired: *

Today's Date: *

Date Available: *

General Information

Name *

First

Middle

Last

Address *

City *

State *

Zip Code *

Home Phone

Work or Message Phone

Email Address *

How did you hear about Manoa Cottage? *

Check Work Availability *

Full-Time
Part-Time
On-Call

Days
PMs
Nights

Temporary
Weekends
Holidays
Other

Apart from absences for religious observances, are there any other specific days or times you cannot work? *

If yes, please list days/times you cannot work:

Do you know anyone presently working for our company? If so, who? *

Personal Information

Have you ever filed an application with Manoa Cottage before? *

If yes, when?

Are you under 18 years of age? (If yes, a work permit will be required.) *

Have you ever been employed with Manoa Cottage before? *

If yes, when and at which facility?

Can you, upon employment, provide proof of eligibility to work in the U.S.? *

Are there any other positions that you are qualified for? *

If yes, please list:

Best time to contact you and at what number: *

Work Experience

Starting with your present or last job, please account for the past 20 years of employment. Include any job related military service assignments or volunteer activities

Employer *

Address *

Telephone Number(s) *

Start Date *

Mo./Yr.

End Date *

Mo./Yr.

Job Title *

Supervisor *

Job Duties and Responsibilities *

Reason For Leaving *

May We Contact *

Employer *

Address *

Telephone Number(s) *

Start Date *

Mo./Yr.

End Date *

Mo./Yr.

Job Title *

Supervisor *

Job Duties and Responsibilities *

Reason For Leaving *

May We Contact *

Employer *

Address *

Telephone Number(s) *

Start Date *

Mo./Yr.

End Date *

Mo./Yr.

Job Title *

Supervisor *

Job Duties and Responsibilities *

Reason For Leaving *

May We Contact *

Employer *

Address *

Telephone Number(s) *

Start Date *

Mo./Yr.

End Date *

Mo./Yr.

Job Title *

Supervisor *

Job Duties & Responsibilities *

Reason For Leaving *

May We Contact? *

Employer *

Address *

Telephone Number(s) *

Start Date *

Mo./Yr.

End Date *

Mo./Yr.

Job Title *

Supervisor *

Reason for Leaving *

May We Contact? *

Comments: Include explanation(s) of any gaps in employment *

Education

Name of High School *

High School City and State *

Course-Degree *

Name of Community College

Community College City and State

Course-Degree

Name of College/University

College City and State

Course-Degree

Name of Nursing, Technical, or Vocational School

Nursing, Technical, or Vocational School City and State

Course-Degree

Other Training or Skills

Course-Degree

What computer applications are you proficient at? (Word, Excel, PowerPoint,etc.)

Professional Licenses and/or Certifications

Are you currently

Licensed
Certified

Type

State Issued

Date

Number

Type

State Issued

Date

Number

Is your license currently under investigation?

List professional, trade, business, or civil activities and offices held. (Exclude any memberships which suggest or disclose your race, color, national origin, religion, disability, or an other protected status.)

Background

Have you ever been discharged and/or asked to resign from employment? *

Have you ever initiated an act of violence in the workplace? *

Please explain any "yes" answer, so that individual circumstances can be considered. A "yes" answer will not necessarily disqualify you. Note: You are only being asked about any misconduct occurring at work. You are not being asked about your criminal record at this time. Please do not provide any information on criminal arrest(s), charge(s), or convictions, if any.

Notice: It is the policy of the company to hire only U.S. citizens and aliens who are authorized to work in this country. (As a condition of employment, you will be required to produce original documents establishing your identity and authorization to work, and complete the U.S. Immigration and Naturalization Service's form I-9.) *

Acknowledged

Personal/Professional References (Do not include family members)

Name *

Phone Number *

Best Time to Call *

Occupation *

Name *

Phone Number *

Best Time to Call *

Occupation *

Name *

Phone Number *

Best Time to Call *

Occupation *

Acknowledgment and Certification

By signing below, I certify that all statements made on this application are true and complete to the best of my knowledge. I understand that my application will not be considered if it is incomplete. Further, I understand that any misrepresentation or omission made herein, when discovered, may subject me to discharge. I authorize Manoa Cottage to investigate my work history, education, character, reputation, and background as it deems necessary for purposes of considering my application for employment. In exchange for Manoa Cottage’s consideration of my application for employment, I hereby release the Company and all providers of information (including, but not limited to, any of my former employers, educational institutions attended, and personal references) from all liability relating to or arising out of any inquiry by Manoa Cottage regarding my work history, education, character, reputation, and background. After an offer of employment is made, but before employment duties begin, applicants may be required to undergo a physical or medical examination (or drug test) at Company expense and by a Company-chosen physician, with the offer of employment conditioned on the result of such examination. Employees, at any time during the course of their employment, may be required to undergo a medical (or drug) examination at Company expense and by a Company-chosen physician. I agree to provide Manoa Cottage with any authorization or release which may be required for a pre-employment medical examination or drug test. This application is not a contract of employment and cannot create a contract of employment for any specific period. I understand that if I am employed, my employment is “at will” and can be terminated at any time, either by myself or the Company, with or without cause or reason and with or without notice. Only the President is authorized to modify the Company’s at-will employment policy or enter into any agreement contrary to this policy. Any such modification must be in writing and signed by the employee and the President. *

Acknowledged

Applicant Signature *

Application Date *

Manoa Cottage considers applications for only a 30-day period. If you wish to be considered after 30 days from the date of your application, please reapply

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