APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

Big Island Substance Abuse Council 16-179 Melekahiwa St., Keaau, HI 96749 Phone: (808) 969-9994 Fax: (808) 969-7375
INSTRUCTIONS: Please complete all portions of this employment 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. We are an equal opportunity employer. We do 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 Company and only for the desired position. Consideration for employment after the three-month period requires completion and submission of a new application.
PERSONAL INFORMATION
Name*

Last NameFirst NameMiddle Name
Have you ever used any other names?*

YesNo
Please print all other aliases (names).
For background and criminal conviction check only. (Separate each name with a semicolon ( ; )
Present Mailing Address*

Street Address

Apt. Number

CityState

Zip Code
Email*

Confirmation EmailEmail Confirmation
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
UPON HIRE, YOU WILL BE REQUIRED TO PRESENT PROOF OF AGE AND AUTHORIZATION TO WORK. CAN YOU UPON EMPLOYMENT, SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES? *If offered employment you will be required to submit documentation required by IRCA

YesNo
DESIRED EMPLOYMENT
Desired Position*
Date you can start*

MonthDayYear
Have you ever applied at this company before?*

YesNo
Where?
Position you applied for
When?
(MM/YYYY)
Have you ever worked for this company before?*

YesNo
Where?
Position held
When?
(MM/YYYY)
Who referred you to this company?*

Employment AgencyNewspaper AdvertisementWalk-inState Employment OfficeBISAC WebsiteOnline (Indeed, Craigslist, etc.)RelativeFriendOther
Name of Relative or Friend who referred you.
Apart from religious observations, can you work any other time? *NOTE: If hired, you will be required to perform work as required by the Company*

YesNo
If no, what are your restrictions
EDUCATION

Please provide your complete name and address if possible. Use NA if Not Applicable.*

	Name and Address of School	Number of Years Attended	Did you Graduate? (Y or N)	Date of Degree (MM/YYYY)
HIGH SCHOOL
COLLEGE
OTHER
OTHER

FORMER EMPLOYERS

For each employee, you will need to answer all questions. Please account for the last ten years of employment
Name of Present or Last Employer*
Your Job Title*
Starting Date*

MonthDayYear
Date
Date Last Worked*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Supervisor*
Title*
Supervisor Phone Number*

Area CodePhone Number
Supervisor Email*

Confirmation EmailEmail Confirmation
May we contact your Supervisor?*

YesNo
If no, why?*
Description of work performed.*
Reason(s) for leaving. If you were terminated or asked to resign, please explain.*
Add another employer?*

YesNo

Former Employer

#2
Name of Last Employer
Job Title
Starting Date

MonthDayYear
Date
Date Last Worked

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name of Supervisor
Title
Supervisor Phone Number

Area CodePhone Number
Supervisor Email

Confirmation EmailEmail Confirmation
May we contact your Supervisor?

YesNo
If no, why?
Description of work performed.
Reason(s) for leaving. If you were terminated or asked to resign, please explain.
Add another employer?

YesNo

Former Employer

#3
Name of Last Employer
Job Title
Starting Date

MonthDayYear
Date
Date Last Worked

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name of Supervisor
Title
Supervisor Phone Number

Area CodePhone Number
Supervisor Email

Confirmation EmailEmail Confirmation
May we contact your Supervisor?

YesNo
If no, why?
Description of work performed.
Reason(s) for leaving. If you were terminated or asked to resign, please explain.
Add another employer?

YesNo

Former Employer

#4
Name of Last Employer
Job Title
Starting Date

MonthDayYear
Date
Date Last Worked

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name of Supervisor
Title
Supervisor Phone Number

Area CodePhone Number
Supervisor Email

Confirmation EmailEmail Confirmation
May we contact your Supervisor?

YesNo
If no, why?
Description of work performed.
Reason(s) for leaving. If you were terminated or asked to resign, please explain.
Add another employer?

YesNo

Former Employer

#5
Name of Last Employer
Job Title
Starting Date

MonthDayYear
Date
Date Last Worked

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Name of Supervisor
Title
Supervisor Phone Number

Area CodePhone Number
Supervisor Email

Confirmation EmailEmail Confirmation
May we contact your Supervisor?

YesNo
If no, why?
Description of work performed.
Reason(s) for leaving. If you were terminated or asked to resign, please explain.

REFERENCES

Please list three (3) business references, whom we may contact.
Reference #1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company*
Job Title*
Phone Number*

Area CodePhone Number
Email*

Confirmation EmailEmail Confirmation
Reference #2*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company*
Job Title*
Phone Number*

Area CodePhone Number
Email*

Confirmation EmailEmail Confirmation
Reference #3*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Company*
Job Title*
Phone Number*

Area CodePhone Number
Email*

Confirmation EmailEmail Confirmation
JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS
Summarize your job skills training and/or studies that are relative to the desired position Also explain any periods that you were not working.*

Upload Documents
Upload your Resume and Letter of Interest*

Browse Files
FILE TYPES: pdf, doc, docx, xls, xlsx, csv, jpg, jpeg, png, zip Cancelof
Upload any Certifications, Degrees, or Licenses

Browse Files
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CERTIFICATION

PLEASE READ CAREFULLY BEFORE SIGNING
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.

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 OT WITHOUT ADVANCE NOTICE.

I understand and agree that only the Chief Executive Officer 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 CEO, and I will not rely upon any other representations.

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. In consideration of the Company's review of this application, I release the Company and all providers of any information from any liability which may arise as a result of furnishing and receiving this information, with the exception of any liability arising from a violation of the Fair Credit Reporting Act ("FCRA" 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.

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 cost of such examination will be paid by the Company. 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.

I agree that 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 (excluding periods of incarceration) or that involves certain Family Court matters will not be considered.

I understand and agree that if offered employment by the Company, I may be required to disclose military service information in accordance with law, and that any such employment offer shall be dependent upon the receipt of a satisfactory military record as determined by the Company.

I understand and agree that all of the foregoing terms and conditions will become part of my employment relationship with the Company if I am employed by the Company.
Authorization/Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Revised 09/2013; 10/2015; 01/2019
Should be Empty:

APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

DESIRED EMPLOYMENT

EDUCATION

FORMER EMPLOYERS

Former Employer

Former Employer

Former Employer

Former Employer

REFERENCES

JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS

Upload Documents

CERTIFICATION