HAWAII DISABILITY RIGHTS CENTER

900 Fort Street Mall, Suite 1040, Honolulu, HI 96813

APPLICATION FOR EMPLOYMENT

I. PERSONAL INFORMATION

The following information is requested in order to help us select the most qualified applicant for open positions within our Center. We appreciate the time you spend completing this application. However, please be aware that the completion of this application in no way guarantees you a position with Hawaii Disability Rights Center.
Last Name First Name Middle Name
Street Address City State Zip Code
Email 1: Email 2:
Home Phone: Work Phone: Cell Phone:

1.

Are you a U.S. citizen or are you legally authorized to work in the U.S.?

Yes No
Note: If offered employment, you will be required to submit documentation as required by the 1986 Immigration Reform and Control Act.

2.

Have you been convicted of a felony within the last 7 years?

Yes No
Note: Conviction will not necessarily disqualify an applicant from employment.

3.

You have read the job description. Are you able to perform the essential functions of this job with or without reasonable accommodations.

Yes No

4.

Apart from absences for religious observances, will you be available to work, as necessary, beyond regular business hours?

Yes No

II. WORK HISTORY

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disability or other protected status.
Employer
Street Address City State Zip Code
Supervisor Email
Work Phone Fax Cell Phone
Job Title Date Employed
Worked Performed
Reason for leaving
Employer
Street Address City State Zip Code
Supervisor Email
Work Phone Fax Cell Phone
Job Title Date Employed
Worked Performed
Reason for leaving
Employer
Street Address City State Zip Code
Supervisor Email
Work Phone Fax Cell Phone
Job Title Date Employed
Worked Performed
Reason for leaving
Employer
Street Address City State Zip Code
Supervisor Email
Work Phone Fax Cell Phone
Job Title Date Employed
Worked Performed
Reason for leaving

III. EDUCATION and QUALIFICATIONS

Name and Location of School # of Years Completed Diploma or Degree Course of Study
High School
Under Graduate
Graduate
Other
Describe any specialized training, skills, activities, honors, awards, etc., which may be helpful to us in considering your application.

IV. REFERENCES

Please provide three references who are not related to you and who are not former employers.
REFERENCE 1:
Name Relationship
Address Email
Home Phone: Work Phone: Cell Phone:
REFERENCE 2:
Name Relationship
Address Email
Home Phone: Work Phone: Cell Phone:
REFERENCE 3:
Name Relationship
Address Email
Home Phone: Work Phone: Cell Phone:
I authorize the Hawaii Disability Rights Center to contact the above-listed references to discuss my qualifications to fill the following position:

V. APPLICANT CERTIFICATION

  • 1. I certify that the information contained in this application is true and correct to the best of my knowledge, and I understand that any false or misleading statements or material omissions, whenever discovered, regarding this application are grounds for disqualification from further consideration or for dismissal from employment.
  • 2. If employed by the Center, I agree to conform to the policies, procedures and practices of the Center, and understand that my employment can be terminated at any time, with or without cause.
  • 3. I understand that only the Executive Director of the Center 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.
  • 4. I authorize the Center to verify all references and information provided by me in this application and release the Center from any claim or liability regarding any information or opinion supplied. I understand that any offer of employment is subject to satisfactory references.
  • 5. I understand and agree that all of the foregoing terms and conditions will become part of my employment agreement with the Center if I am employed by the Center.