Referred by:
Application for Employment
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color,
age, sex, religion, disability, medical condition, national origin, or marital status.
Important Note:
This form should be completed carefully and fully
.
Please answer all questions thoroughly to the best of your ability
and write legibly.
(Incomplete application will not be processed!)
Name:
Date
Physical Address:
Previous Address if less than 5 years at current physical address:
Mailing Address:
Email Address:
Home Phone Number:
Cellular Phone:
Alternate Phone:
Social Security Number:
Emergency Contact
Address:
Relationship:
Phone:
Name:
I am applying for a position as a:
Are you 18 years old or older?
Have you ever been convicted of a felony?
If yes, please provide details:
Transportation
(Many Caregiver positions require the Caregiver to transport a Client.)
Do you have dependable transportation?
Make and Model of Car:
License Plate #: Driver’s License #:
Auto Insurance Policy #:
Insurance Company:
Insurance Phone:
Have you had any accidents during the past three years? If so, how many?
Have you had any moving violations in the past three years? If so, How many?
Availability
Days and Hours you are available to work:
Days Hours
Amount of Wage currently
getting or Last Paid:
Wage currently seeking:
Are you available to work on holidays?
Can you be called at the last minute in
case of emergency?
Date available to start work:
Shift Preference: Circle your preference
Morning Shift
Evening Shift
Which Island are you applying from:
Big Island of Hawaii Island of Oahu Island of Maui
Which of the following areas can and will you travel to? Check all that apply.
Big Island of Hawaii
North Kohala
South Kohala
North Kona
South Kona
Hamakua
Hilo
Puna
Kau
Oahu
Leeward
Windward
North Shore
Kahuku/Punalu’u
Central
Downtown
East Honolulu
Hawaii Kai
Maui
Lahaina
Kahului/Wailuku
Upcounty/North Shore
Kihei/Wailea
Experience
For Caregiver Applicant:
Briefly describe any training or experience working with the elderly or special needs individuals:
For Administrative Applicant:
Briefly describe any training or experience working in the Home Care Industry?
Please describe any
Skills, Strength and Attributes
that people like about you, which make you a good candidate to be a part
of the MetroCare Hawaii - PLUS family.
For Caregiver Applicant:
What would you
like most
about working with the elderly or special needs individuals and why?
For Caregiver Applicant:
What would you
like least
about working with the elderly or special needs individuals and why?
Education
High School
City/State
Dates
College
Professional School
Other
City/State
City/State
City/State
Dates
Dates
Dates
Degrees/Certificates
Special Skill or Courses
Employment History
(Please go back at least five (5) years and tell us about your work history, Use reverse side of sheet if additional space is required.) Please
begin with the most recent employer.
May we contact your current employer?
Yes
No
Company Name & Address:
Employment Dates
From
To
Job Title:
Pay Rate
Start: $ Last: $
Duties
Reason for leaving: (Be Specific)
Supervisor:
Phone:
Company Name & Address:
Employment Dates
From
To
Job Title:
Pay Rate
Start: $
Per Hour
/Month
Last: $
Per Hour
/Month
Duties
Reason for leaving: (Be Specific)
Supervisor:
Phone:
Company Name & Address:
Employment Dates
From
To
Job Title:
Pay Rate
Start: $
Per Hour
/Month
Last: $
Per Hour
/Month
Duties
Reason for leaving: (Be Specific)
Supervisor:
Phone:
Business References
(Minimum of 2 work related)
Name
Address Relationship/Years Known
Phone Number
Name
Address Relationship/Years Known
Phone Number
Name
Address
Relationship/Years Known
Phone Number
Personal References
(Minimum of 2 personal related)
Address
Name
Relationship/Years Known
Phone Number
Name
Address Relationship/Years Known
Phone Number
Name
Address Relationship/Years Known
Phone Number
Certification and Release:
I certify that I have read and understand the application form and that the stated and indicated answers to the foregoing questions and
statements made by me are complete true in fact and no misrepresentation of myself has been made to the best of my knowledge and
belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in
rejection of this application and/or discharge at any time during my employment. I authorize
MetroCare Hawaii - PLUS and/or its’ agents,
including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle
driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my
background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any
damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during my employment and
that I am not in any way, shape or form at present in the possession or use of illegal drugs and that I am willing to submit to drug testing
at any time to detect the use of illegal drugs prior to or during my employment.
Employment Agreement Clarification:
This application is not an employment agreement. If I accept an offer of employment, I understand that MetroCare Hawaii - PLUS may
terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one,
other than an executive officer of the Agency has the authority to enter into any employment agreement with terms contrary to the
foregoing and then only in writing signed by such officer. I fully understand and accept all the terms and conditions in the above
statement.
Applicant’s Signature
Date
MetroCare Hawaii - PLUS
believes that the information solicited from the applicant is in full compliance with all Federal and State equal
employment laws and with the Fair Credit Reporting Act. We do not assume responsibility for the user’s inclusion in this “Application for
Employment” of any question which may violate Federal, State or Local Laws and users should consult their own Council with respect to
any legal questions concerning the use of this form.
Application Expiration:
This application will expire in 60 days. After that date, unless otherwise notified, I understand that my status as
an applicant will end. I may re-apply for employment in the future by completing a new application.
For Office Use Only – Interviewer Comments
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