Employment Application

Manoa Cottage Application for Employment

Equal Employment Opportunity. Manoa Cottage & Manoa Cottage Kaimuki provides equal employment opportunities consistent with applicable federal, Hawai‘i, and local law. Employment decisions are made without unlawful discrimination based on protected characteristics or protected activity, including race, color, religion, sex (including pregnancy, sexual orientation, gender identity or expression), national origin, ancestry, age, disability, genetic information, marital status, arrest and court record, credit history, domestic or sexual violence victim status, reproductive health decisions, breastfeeding, National Guard or military/veteran status, or any other status protected by law. Reasonable accommodation is available for qualified applicants with disabilities and for known limitations related to pregnancy, childbirth, or related medical conditions, as required by 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

Time Availability *

Days
PMs
Nights

Other Availability

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? *

If yes, you may briefly explain the circumstances below. Do not provide information about arrests, charges, convictions, sealed/expunged matters, or other criminal-history information on this application. Any lawful conviction inquiry, if applicable, will occur separately at the stage permitted by Hawai‘i law and any applicable statutory exception.

Notice: It is the policy of Manoa Cottage and Manoa Cottage Kaimuki 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 to 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 typing/signing my name below, I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that material misrepresentations or omissions may result in withdrawal of an offer or, if discovered after hire, corrective action up to and including termination, consistent with applicable law. I authorize Manoa Cottage & Manoa Cottage Kaimuki to verify the job-related information provided in this application, including employment history, education, licenses/certifications, and references, as permitted by law. Any background check conducted by a third-party consumer reporting agency will be managed through separate disclosures, authorizations, and notices required by applicable law. After a conditional offer, Manoa Cottage & Manoa Cottage Kaimuki may require job-related and legally permissible post-offer screening or medical examination for individuals entering the same job category, consistent with applicable law. Medical information will be managed confidentially as required by law. Nothing in this application requires disclosure of disability, genetic information, pregnancy status, or other medical information. This application is not a contract of employment. If hired, employment with Manoa Cottage & Manoa Cottage Kaimuki is at will to the fullest extent permitted by Hawai‘i law, meaning either the employee or Manoa Cottage & Manoa Cottage Kaimuki may end the employment relationship at any time, with or without cause or advance notice, subject to applicable law and any written agreement signed by an authorized representative of Manoa Cottage & Manoa Cottage Kaimuki. *

Acknowledged

Applicant Signature *

Application Date *

Manoa Cottage & Manoa Cottage Kaimuki 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.

Acknowledged

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