Fillable EMPLOYMENT APPLICATION

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EMPLOYMENT APPLICATION

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AMERICAN SAMOA GOVERNMENT
Department Of Human Resources
Pago Pago, AS 96799
Employment Service Branch: 684.633.4485
Contract Recruitment Branch: 684.633.5357
EMPLOYMENT
APPLICATION
Page 2 of 6
IMPORTANT: Please read the instructions carefully before filling in each section. Answer each
question briefly, but as completely as required. If you need additional space, use that provided by
Section 14 or attach an extra sheet of paper to the application (be sure to identify the section number of
the question you are answering in Section 14). Type or print clearly your answers in the space provided.
If an item does not apply to you or if there is no information to be given, please write in the space
provided NA, meaning not applicable. This application will be used for evaluation only. You are in no
way obligating yourself by submitting it nor is its acceptance by the American Samoa Government to be
interpreted as a commitment of any kind. Non-resident applicants are asked to include marital and
dependent information on a supplemental form. If you need information about employment or
assistance to complete this application form please contact a representative of the Recruitment Section of
the Department of Human Resources - Personnel Division. A completed application requires the
following attached forms:
EQUAL EMPLOYMENT OPPORTUNITY
There shall be no discrimination in employment against any person on the basis of race, religious beliefs,
political beliefs, color, age, sex, national origin, marital status, or physical and mental handicap, except
for bona fide occupational or legal requirements.
1. Birth Certificate or Passport
2. Social Security Card
3. Official Photo Identification Document
4. Copies of Educational or Vocational Diploma, Degree and/or Certificate
5. If you are not a US Citizen or US National, please provide a copy of your
Immigration ID and Immigration Board hearing result
6. Resume
7. Three Letters of Recommendation (Optional)
8. Official Transcripts (if appropriate)
Page 3 of 6
DO NOT WRITE IN THIS BLOCK
Date received
Screening No. Veteran's Preference
Typing Shorthand ASG Skill Code Register
1. JOB PREFERENCE: Please list and describe the types of jobs which, as an employee, you would feel most qualified to
perform and in which you would prefer to work (list in order of preference).
First:
Second:
Third:
2. List any special qualifications and skills (for example, skills with tools, word processing, dictation machine or other
equipment:
3.
Licenses and Certificates State or Other Licensing Authority Validation Date
4.
Do you have a valid diver's license? Commercial driver's license?
5. EDUCATION
a. Circle highest school grade completed: 1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16
b.
Name and Location of
College or University
Dates Attended Years
Completed
Attendance Total Number of
Credits
Years/Degree
Earned
From To Part
Time
Full
Time
c. Principal Courses of Study:_________________________________________________________________
d. Other schools or training (for example, trade, vocational, armed forces or business): Give name and location
(city, state and zip code if known) of school, dates attended, subjects studied, number of classroom hours of
instruction per week, certificates, and any other pertinent information.
__________________________________________________________________________________________
__________________________________________________________________________________________
Page 4 of 6
6. EXPERIENCE: Start with your PRESENT position and work back. Account for periods of unemployment in Section 14.
May inquiry be made of your present employer regarding your character, qualifications and record of employment? (A
"No" answer will not affect your consideration for employment opportunities.) Yes □ No □
b.
Dates of employment (month, year)
From: To:
Job title:
Present salary: $
per Type of business/organization:
Number of employees supervised: Contact Info. Tel: Email:
Name of immediate supervisor: Reason for wanting to leave:
Employer: Address:
Job Duties:
a.
Dates of employment (month, year)
From: To:
Job title:
Present salary: $
per Type of business/organization:
Number of employees supervised: Contact Info. Tel: Email:
Name of immediate supervisor: Reason for wanting to leave:
Employer: Address:
Job Duties:
c.
Dates of employment (month, year)
From: To:
Job title:
Present salary: $
per Type of business/organization:
Number of employees supervised: Contact Info. Tel: Email:
Name of immediate supervisor: Reason for wanting to leave:
Employer: Address:
Job Duties:
d.
Dates of employment (month, year)
From: To:
Job title:
Present salary: $
per Type of business/organization:
Number of employees supervised: Contact Info. Tel: Email:
Name of immediate supervisor: Reason for wanting to leave:
Employer: Address:
Job Duties:
Page 5 of 6
7.
Languages Used Spoken Written
Samoan Excellent: Fair: Poor: Excellent: Fair: Poor:
English Excellent: Fair: Poor: Excellent: Fair: Poor:
Other Excellent: Fair: Poor: Excellent: Fair: Poor:
8.
References: Your selection of references is very important. Choose people who are personally acquainted with your
capabilities and talents. Be sure to inform your references that they will be contacted by a representative of the American
Samoa Government, and urge them to respond promptly. Do not repeat names of supervisors listed in Section 8.
Full Name Contact Information: Address/Tel/Fax/Email Business/Occupation
9. Are you now or have you been within the last ten (10) years a member of the Communist Yes
No
party or any subdivision of the Communist party or a member of any other organization
or group of persons which during the period of your membership you knowingly
advocated the overthrow of the Government of the United States or American Samoa?
10. Within the last five (5) years have you been fired from any job for any reason?
Yes
No
If yes explain below.
11. Within the last five (5) years have you resigned from any job after having been notified
Yes
No
that you would be suspended or fired? If yes explain below.
12. Have you ever been convicted of a crime or forfeited collateral, or are you now under
Yes
No
charges for any for a crime other than minor traffic offenses? You may answer No
if the conviction occurred before your 21st birthday. If yes explain below.
13. If you were a member of the military were you honorably discharged?
Yes
No
If not explain below.
14. Space for detailed answers. Please indicate item number to which your answers apply.
Section No.
e.
Dates of employment (month, year)
From: To:
Job title:
Present salary: $
per Type of business/organization:
Number of employees supervised: Contact Info. Tel: Email:
Name of immediate supervisor: Reason for wanting to leave:
Employer: Address:
Job Duties:
Page 6 of 6
15.
Mr. Mrs. Miss.
(please circle)
Name, Last First MI Maiden
Home Telephone No. Address (street or Post Office Box Number):
Office Telephone No. City or Village and State: Zip Code
Social Security No. Birthplace: Date of birth:
Legal Voting Residence Height without shoes: Weight
The following information is needed for the Government of American Samoa's Affirmative Action Program. This
information is not intended to prevent anyone unlawfully from employment. It is to ensure equal employment
opportunities. Only when the information below is directly related to the minimum qualifications of a specific position will
this information be made available to a selecting official. In all cases of employment however, first consideration shall be
given to persons eligible for permanent residence within the Territory of American Samoa.
16. Check Ethnic Origin: Polynesian Caucasian Black Asian Other
17. Check Citizenship: American Samoa United States
18. If you were not born in American Samoa complete the following:
a. Was one of your parents born in American Samoa? Yes
No
b. Are you married to an American Samoan? If yes provide name and village of spouse. Yes
No
___________________________________ _________________________________
c. Were you legally adopted by an American Samoan? Yes
No
d. Has the American Samoa Immigration Board granted you permanent residence? If Yes
No
yes please provide documentation.
ATTENTION: After completing all questions, please sign and date. A false answer to any question may be grounds for
non-employment or for discharge after employment. All statements are subject to investigation, including a check of police
records and contacting former employers.
BY SIGNING BELOW I CERTIFY THAT ALL THE STATEMENTS MADE ON THIS APPLICATION ARE TURE,
COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THE AMERICAN SAMOA
GOVERNMENT, DEPARTMENT OF HUMAN RESOURCES, IS AUTHORIZED TO VERIFY MY CREDENTIALS AND
PRIOR EMPLOYNMENT SET FORTH IN THIS APPLICATION.
Date:
Applicant's Signature
Other
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EMPLOYMENT APPLICATION

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Completed 30 July 2021

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