Fillable State of Hawaii - HRD278 Application for Non Civil Service Appointment

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State of Hawaii - HRD278 Application for Non Civil Service Appointment

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The State of Hawaii - HRD278 Application for Non Civil Service Appointment form is 5 pages long and contains:

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IMPORTANT INFORMATION FOR STATE OF HAWAII NON-CIVIL SERVICE EMPLOYMENT


             
  
              
            
   
            


      
        

           
             
            

           
                 
              

  
 
          

     
        
              
       
        
  
          


Form HRD 278 (Rev. 2/2019)
State of Hawai‘i Department of Human Resources Development
GENERAL INSTRUCTIONS TO APPLICANT: Please type or print legibly in blue or black ink.
The information you provide will be used to determine whether you qualify for the job(s), for which you are applying.
Your entire application and attachments (if any) must be received only at the Personnel Office above.
This application form is to be used for non-civil service appointments.
Before applying, read the position requirements described in the Announcement carefully to determine if you qualify for the position.
Any additional required forms described in the Announcement can be obtained from this office.
Answer the questions completely and accurately. Your application may be rejected if it is incomplete or you may be disqualified or
dismissed from employment if you provide false information.
You must notify this office in writing of any changes to your name, addresses, telephone numbers or availability information.
We will not be responsible for any mail or correspondence which does not reach you.
Your application and supporting documents are confidential and become our property. Please keep copies for your own record.
The information you submit on this form may be verified.
The information on pages 1 and 2 will not be released to persons involved in the appointment process.
The State of Hawai‘i is an equal opportunity employer and complies with applicable state and federal laws relating to employment practices.
Page 1
9.
NOTICE OF “AT WILL” EMPLOYMENT
The job you are applying for is temporary in nature. Therefore,
if appointed to the position, your employment will be considered
to be “At Will,” which means that you may be discharged from
your employment at the prerogative of the department head or
designee at any time.
CERTIFICATE OF APPLICANT
I have been informed and understand that this application is for
consideration of a job that is temporary in duration, has limited or
no benefits, and employment, if offered, is only on an “At Will”
basis. I hereby certify that all statements in this application are
true and correct to the best of my knowledge, and I agree and
understand that any misstatements of material facts herein may
cause forfeiture of all rights to any employment in the service of
the State of Hawai‘i. I have read the terms or conditions stated on
this application and understand that there may be additional
employment-related tests as required.
Date Original Signature of Applicant
FOR OFFICIAL USE ONLY
DEPARTMENTAL PERSONNEL STAFF
TO SELECT CATEGORY.
RECEIVED DATE/TIME STAMP
8. WORK AUTHORIZATION
A. Are you legally authorized to work in the United
States? Yes No
B. Will you now or in the future require sponsorship by
the State of Hawaii for employment visa status
(e.g. H-1B visa status)? Yes No
City State Zip Code
PHONE
NUMBER:
Home Other
1.
2.
3.
4.
5.
6.
7.
POSITION TITLE APPLYING FOR
RECRUITMENT NUMBER or POSITION NUMBER
NAME:
Last First Middle
MAILING
ADDRESS:
P.O. Box or Number and Street
OTHER NAMES
USED OR FORMER
LAST NAME:
E-MAIL
ADDRESS:
TAOL
___________
Exempt
89 Day
STATE OF HAWAI‘I APPLICATION
FOR NON-CIVIL SERVICE APPOINTMENT
DEPARTMENT OF HUMAN SERVICES
Personnel Office / RES
P.O. Box 339, Honolulu, Hawaii 96809-0339
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   
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Page2
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v.

9
Form HRD 278 (Rev. 2/2019)
State of Hawai‘i Department of Human Resources Development
STATE OF HAWAI‘I DEPARTMENT OF HUMAN SERVICES
EDUCATION AND EMPLOYMENT HISTORY
STATE OF HAWAI‘I APPLICATION FOR NON-CIVIL SERVICE APPOINTMENT
Page 3
1. POSITION TITLE APPLYING FOR:
2. RECRUITMENT NUMBER or POSITION NUMBER:
B. TRAINING: In-service training, business, trade, armed forces, college or university, graduate of professional schools.
NAME & ADDRESS
DO NOT
WRITE
IN THIS
SPACE
NAME:
Last First Middle
7. PHONE NO.:
Home Other
3.
4.
5.
6.
Did you graduate? Yes No If no, what grade level did you complete? _____
Did you receive a GED? Yes No
C. KNOWLEDGE OF LANGUAGE OTHER THAN ENGLISH:
List the
language and check the appropriate block(s). Some positions require the ability
to speak, read, and/or write in a language other than English.
D. SPECIAL QUALIFICATIONS: Include membership in professional
or scientific societies, honors, awards, fellowships, publications (list but
do not submit unless requested), etc.
LANGUAGE SPEAK READ WRITE
As required by federal and/or state laws, we do not discriminate
on the basis of age, sex (including gender identity or
expression), religion, race, color, ancestry, national origin,
disability, marital status, veteran’s status, sexual orientation,
arrest and court record, citizenship, genetic information or any
other protected characteristic. The State of Hawai‘i is an equal
opportunity employer and complies with applicable state and
federal laws relating to employment practices.
8. EDUCATION HISTORY:
When verification is required, the documentation must be submitted at the time of the application. If not, you may not receive credit
for the training and/or your application may be considered incomplete and rejected. The information you provide in this section will be used strictly in the evaluation of
your qualifications for the position(s) for which you are applying. The information you submit on this form may be verified.
A.NAME AND LOCATION (city and state) of last grade school attended: (elementary, intermediate or high school)
(School name/type) (City/State/Country)
Course or Major Number of Credits
Field of Study or Hours Completed
Kind of Degree,
Diploma or Certificate
Received
Semester Quarter
9. LICENSES, CERTIFICATES, OTHER QUALIFICATIONS
A. DRIVER’S LICENSE:
B. OTHER LICENSES OR CERTIFICATES: Please indicate the kind, registration number, and the State or other licensing authority. If proof of
evidence is required, please submit a photocopy or present for verification.
MAILING
ADDRESS:
P.O. Box or Number and Street
City State Zip Code
OTHER NAMES
USED OR FORMER
LAST NAME:
E-MAIL
ADDRESS:
Yes, I have a valid driver’s license or I am able to obtain a valid driver’s license by the time of appointment.
No, I do not have a driver’s license and/or I am not interested in being considered for positions which require
a driver’s license.
TAOL
_________
Exempt
89 Day
DEPARTMENTAL PERSONNEL
STAFF TO SELECT CATEGORY
FOR OFFICIAL USE ONLY
Form HRD 278 (Rev. 2/2019)
State of Hawai‘i Department of Human Resources Development
10. EXPERIENCE: Please type or print legibly in ink. Begin with your present or last employment/training and work backwards. Describe all
employment/training, including military service and volunteer work. Use separate blocks if your duties and responsibilities changed while working for
the same employer. To receive full credit for your experience, describe in detail the tasks you were assigned. If you supervised others, explain your
duties as a supervisor and indicate the number and job duties of employees you supervised. If more space is needed provide the information on a blank
sheet titled “Experience” and attach it to this form. Information you submit on this form may be verified.
Do not submit a resume in place of completing this page.
Page 4
Your Present or Last Position
From: _________________________________
To: ____________________________________
Full Time PartTime Volunteer
Average hours worked per week ____________
Reason(s) for leaving ____________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
May we contact this employer? Yes No
Month Year
Month Year
From: _________________________________
To: ____________________________________
Full Time PartTime Volunteer
Average hours worked per week ____________
Reason(s) for leaving ____________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
May we contact this employer? Yes No
Month Year
Month Year
From: _________________________________
To: ____________________________________
Full Time PartTime Volunteer
Average hours worked per week ____________
Reason(s) for leaving ____________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
May we contact this employer? Yes No
Month Year
Month Year
Employer ____________________________________________________
Address _____________________________________________________
_______________________________________________________________
Supervisor’s Name and Title ______________________________________
Company Phone Number _________________________________________
Company URL Internet Address ____________________________________
Your Position Title and Duties ______________________________________
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________________________________
__________________________________________________________________________
Did you supervise? Yes No If yes, how many employees?_____
Employer ____________________________________________________
Address _____________________________________________________
_______________________________________________________________
Supervisor’s Name and Title ______________________________________
Company Phone Number _________________________________________
Company URL Internet Address ____________________________________
Your Position Title and Duties ______________________________________
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________________________________
__________________________________________________________________________
Did you supervise? Yes No If yes, how many employees?_____
Employer ____________________________________________________
Address _____________________________________________________
_______________________________________________________________
Supervisor’s Name and Title ______________________________________
Company Phone Number _________________________________________
Company URL Internet Address ____________________________________
Your Position Title and Duties ______________________________________
_______________________________________________________________________
____________________________________________________________________________
__________________________________________________________________________
Did you supervise? Yes No If yes, how many employees?_____
Employer _________________________________________________
Address __________________________________________________
______________________________________________________________
Supervisor’s Name and Title ____________________________________
Company Phone Number _____________________________________
Company URL Internet Address _________________________________
Your Position Title and Duties ___________________________________
_______________________________________________________________
________________________________________________________________
_______________________________________________________________
_______________________________________________________________
________________________________________________________________
Do you supervise? Yes No If yes, how many employees?_____
Month Year
Month Year
From: _________________________________
To: ____________________________________
Full Time Part Time Volunteer
Average hours worked per week ____________
Reason(s) for leaving ____________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
May we contact this employer? Yes No
EDUCATION AND EMPLOYMENT HISTORY
STATE OF HAWAI‘I APPLICATION FOR NON-CIVIL SERVICE APPOINTMENT
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State of Hawaii - HRD278 Application for Non Civil Service Appointment

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Completed 24 May 2020

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