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STATE OF HAWAI‘I APPLICATION FOR NON-CIVIL SERVICE APPOINTMENT

UNIVERSITY OF HAWAI'I

OFFICE OF HUMAN RESOURCES

2440 Campus Road

Administrative Services Building #2

Honolulu, Hawaii 96822-2246

FOR OFFICIALUSE ONLY

DEPARTMENTALPERSONNELSTAFF

TOSELECTCATEGORY.

Exempt		TAOL
89 Day
89 Day	___________

RECEIVED DATE/TIME STAMP

GENERALINSTRUCTIONSTOAPPLICANT: Please type orprint legibly in blue orblack 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 theAnnouncement carefully to determine if you qualify for the position.

AnyadditionalrequiredformsdescribedintheAnnouncementcanbeobtainedfromthisoffice.

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.

Youmustnotifythisofficeinwritingofanychangestoyourname,addresses,telephonenumbersoravailabilityinformation.

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.

TheStateofHawai‘iisanequalopportunityemployerandcomplieswithapplicablestateandfederallawsrelatingtoemploymentpractices.

POSITION TITLE APPLYING FOR

RECRUITMENT NUMBER or POSITION NUMBER

3.NAME:

Last

First

Middle

OTHERNAMES

USEDORFORMER

4.LASTNAME:

MAILING

5.ADDRESS:

P.O. Box	or	Number and Street

City	State	Zip Code

E-MAIL

6.ADDRESS:

PHONE

7.NUMBER:

Home Other

8.CITIZENSHIPSTATUS.

The State of Hawai‘i requires that all persons seeking employment with the government of the State shall be citizens, nationals, or permanent resident aliens of the UnitedStates,oreligibleunderfederallawforunrestricted employment in the United States.

I acknowledge I have read and understood the above information.

9.NOTICEOF“ATWILL”EMPLOYMENT

Thejobyouareapplyingforistemporaryinnature. Therefore, ifappointedtotheposition,youremploymentwillbeconsidered to be “AtWill,” which means that you may be discharged from your employment at the prerogative of the department head or designee at any time.

CERTIFICATE OFAPPLICANT

I have been informed and understand that this application is for considerationofajobthatistemporaryinduration,haslimitedor 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 theStateofHawai‘i. Ihavereadthetermsorconditionsstatedon this application and understand that there may be additional employment-related tests as required.

Date	Original Signature ofApplicant

StateofHawai‘iDepartmentofHumanResourcesDevelopment

Page 1

FormHRD278(Rev.10/2013)

STATE OF HAWAI‘I APPLICATION FOR NON-CIVIL SERVICE APPOINTMENT

The information on pages 1 and 2 will not be released to persons involved in the appointment process.

Informationrequestedinitems10through19isneededtomakedeterminationsonyoursuitabilityforemployment.Dismissals fromemploymentordishonorableseparationsfrommilitaryservicedonotautomaticallydisqualifyyoufromemployment. The circumstances of each individual case will be evaluated against the requirements of the position for which you have applied, to determine suitability for employment.

10. DISMISSALSFROMEMPLOYMENTAND/ORDISHONORABLESEPARATIONSFROMMILITARYSERVICE

Withinthepastfiveyears,wereyou:
A)Fired,terminatedforcause,dismissed,dischargedoraskedtoresignfromemployment?	YES	NO
B)Separatedfrommilitaryserviceunderconditionsotherthanhonorable?	YES	NO

(If you answer “Yes” to question 10Aor 10B, please explain in detail in item #11 below, the dates and reasons for your dismissal from employment or separation from military service. For dismissals from employment, provide also the name and address of the employer.)

11.____________________________________________________________________________________________

____________________________________________________________________________________________________________

12.WITHINTHEPASTTHREE(3)YEARS,HAVEYOUBEENCONVICTEDOFANY

OFFENSE RELATEDTO CONTROLLED SUBSTANCES?

YES

(If you answer “Yes” to the above question, pleaseexplainindetailinitem#13below,the dates, nature and circumstances of the conviction; the sentence imposed and its current status; and any other relevant information you wish to provide.)

13.____________________________________________________________________________________________

____________________________________________________________________________________________________________

14.HAVEYOU EVER BEEN CONVICTED OFANYACT,ATTEMPTOR CONSPIRACYTO

OVERTHROWTHE STATE OR FEDERALGOVERNMENTBYFORCE ORVIOLENCE?

YES

(If you answer “Yes” to the above question, pleaseexplainindetailinitem#15below,the dates, nature and circumstances of the conviction; the sentence imposed and its current status; and any other relevant information you wish to provide.)

15.____________________________________________________________________________________________

____________________________________________________________________________________________________________

16.SUSPENSIONORREVOCATIONOFLICENSE

Wasyourlicenseorcertificationtopracticeinaregulatedprofession(forexample,

physician,engineer,nurse,plumber,etc.)eversuspendedorrevoked?

YES

(Ifyouanswer“Yes,”pleaseexplainindetailinitem#17below,thetypeoflicense;thedate;thestate;thespecific board or organization that suspended or revoked your license; the circumstances of the suspension or revocation; and any other relevant information you wish to provide.)

17.____________________________________________________________________________________________

____________________________________________________________________________________________________________

18.SETTLEMENTSORAGREEMENTS

Haveyouacceptedasettlement,acashbuyoutsuchasthroughtheState’sSeparationIncentiveProgram

orareyousubjecttoanyrestrictionlimitingorprecludingyoufromseekingorsecuringemployment
withtheStateofHawai‘i?	YES	NO
(Ifyouanswer“Yes,”toquestion18,pleaseexplainindetailinitem#19below,thereasonanddateofyoursettlement
orrestrictionfromapplyingwiththeStateofHawai‘i.)

19._____________________________________________________________________________________________

____________________________________________________________________________________________________________

StateofHawai‘iDepartmentofHumanResourcesDevelopment

Page 2

FormHRD278(Rev.10/2013)

STATE OF HAWAI‘I UNIVERSITY OF HAWAI'I – OFFICE OF HUMAN RESOURCES	FOR OFFICIAL USE ONLY
	FOR OFFICIAL USE ONLY
EDUCATION AND EMPLOYMENT HISTORY
EDUCATION AND EMPLOYMENT HISTORY	DEPARTMENTAL PERSONNEL
STATE OF HAWAI‘I APPLICATION FOR NON-CIVIL SERVICE APPOINTMENT	DEPARTMENTAL PERSONNEL
	STAFF TO SELECT CATEGORY
	STAFF TO SELECT CATEGORY
1. POSITION TITLEAPPLYING FOR:	Exempt	TAOL
1. POSITION TITLEAPPLYING FOR:
2. RECRUITMENT NUMBER or POSITION NUMBER:	89 Day	_________

Asrequiredbyfederaland/orstatelaws,wedonotdiscriminate 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, arrestandcourtrecord,citizenship,geneticinformationorany otherprotectedcharacteristic.TheStateofHawai‘iisanequal opportunityemployerandcomplieswithapplicablestateand federal laws relating to employment practices.

3.	NAME:
		Last		First	Middle
4.	OTHER NAMES
USED OR FORMER
	LAST NAME:
5.	E-MAIL
	ADDRESS:
6.	MAILING
	ADDRESS:
		P.O. Box	or	Number and Street

		City		State	Zip Code

7.PHONENO.:

				Home	Other
8.EDUCATIONHISTORY:Whenverificationisrequired,thedocumentationmustbesubmittedatthetimeoftheapplication.Ifnot,youmaynotreceivecredit						DO NOT
forthetrainingand/oryourapplicationmaybeconsideredincompleteandrejected.Theinformationyouprovideinthissectionwillbeusedstrictlyintheevaluationof						WRITE
your qualifications for		the	position(s) for which you are applying. The information you submit on		this form may be verified.	IN THIS
						SPACE
A.NAMEAND LOCATION (city and state) of last grade school attended: (elementary, intermediate or high school)
(School name/type)				(City/State/Country)

	Did you graduate?	Yes	No If no, what grade level did you complete? _____
	Did you receive a GED?		Yes	No

B.TRAINING:In-servicetraining,business,trade,armedforces,collegeoruniversity,graduateofprofessionalschools.

NAME & ADDRESS

CourseorMajor	NumberofCredits		KindofDegree,
FieldofStudy	orHoursCompleted		DiplomaorCertificate
	Semester	Quarter	Received

9.LICENSES,CERTIFICATES,OTHERQUALIFICATIONS

A.DRIVER’SLICENSE:

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.

B. OTHER LICENSES OR CERTIFICATES: Please indicate the kind, registration number, and the State or other licensing authority. If proof of evidenceisrequired,pleasesubmitaphotocopyorpresentforverification.

C. KNOWLEDGE OF LANGUAGE OTHER THAN ENGLISH: List the languageandchecktheappropriateblock(s).Somepositionsrequiretheability tospeak,read,and/orwriteinalanguageotherthanEnglish.

D. SPECIAL QUALIFICATIONS: Include membership in professional or scientific societies, honors, awards, fellowships, publications (list but donotsubmitunlessrequested),etc.

LANGUAGE

SPEAK READ

WRITE

StateofHawai‘iDepartmentofHumanResourcesDevelopment

Page 3

FormHRD278(Rev.10/2013)

EDUCATION AND EMPLOYMENT HISTORY

STATE OF HAWAI‘I APPLICATION FOR NON-CIVIL SERVICE APPOINTMENT

10.EXPERIENCE: Please type or print legibly in ink. Begin with your present or last employment/training and work backwards. Describe all employment/training,includingmilitaryserviceandvolunteerwork. Useseparateblocksifyourdutiesandresponsibilitieschangedwhileworkingfor the same employer. To receive full credit for your experience, describe in detail the tasks you were assigned. If you supervised others, explain your dutiesasasupervisorandindicatethenumberandjobdutiesofemployeesyousupervised.Ifmorespaceisneededprovidetheinformationonablank sheettitled“Experience”andattachittothisform.Informationyousubmitonthisformmaybeverified.

Donotsubmitaresumeinplaceofcompletingthispage.

POSITION		Employer_________________________________________________			From:_________________________________

		Address__________________________________________________			Month		Year
					To:____________________________________
		______________________________________________________________			Month		Year
LAST		Supervisor’sNameandTitle ____________________________________			FullTime	PartTime	Volunteer
		CompanyPhoneNumber _____________________________________			Averagehoursworkedperweek		____________
		CompanyURLInternetAddress_________________________________
OR		YourPositionTitleandDuties___________________________________			Starting Salary	$___________ Per ______

PRESENT		_______________________________________________________________			Ending Salary	$___________ Per ______
		________________________________________________________________			Reason(s)forleaving_____________________
		_______________________________________________________________			________________________________________________
		_______________________________________________________________			________________________________________________
YOUR		________________________________________________________________			Maywecontactthisemployer?		Yes	No
		Doyousupervise?	Yes	No Ifyes,howmanyemployees?_____


Employer____________________________________________________					From:_________________________________
Address_____________________________________________________					Month		Year
					To:____________________________________
	_______________________________________________________________
						Month	Year
Supervisor’sNameandTitle ______________________________________					FullTime	PartTime	Volunteer
CompanyPhoneNumber _________________________________________					Averagehoursworkedperweek		____________
CompanyURLInternetAddress____________________________________
YourPositionTitleandDuties______________________________________					Starting Salary	$___________ Per ______
_______________________________________________________________________					Ending Salary	$___________ Per ______
________________________________________________________________________					Reason(s)forleaving_____________________
________________________________________________________________________					________________________________________________
____________________________________________________________________________					________________________________________________
__________________________________________________________________________
Didyousupervise?			Yes	No Ifyes,howmanyemployees?_____	Maywecontactthisemployer?		Yes	No

Employer____________________________________________________					From:_________________________________
Address_____________________________________________________					Month		Year
_______________________________________________________________					To:____________________________________
Supervisor’sNameandTitle ______________________________________					Month		Year
					FullTime	PartTime	Volunteer
CompanyPhoneNumber _________________________________________					Averagehoursworkedperweek		____________
CompanyURLInternetAddress____________________________________
YourPositionTitleandDuties______________________________________					Starting Salary	$___________ Per ______
_______________________________________________________________________					Ending Salary	$___________ Per ______
________________________________________________________________________					Reason(s)forleaving_____________________
________________________________________________________________________
____________________________________________________________________________					________________________________________________
__________________________________________________________________________					________________________________________________
Didyousupervise?			Yes	No Ifyes,howmanyemployees?_____	Maywecontactthisemployer?		Yes	No

Employer____________________________________________________					From:_________________________________
Address_____________________________________________________					Month		Year
					To:____________________________________
_______________________________________________________________					Month		Year
Supervisor’sNameandTitle ______________________________________					FullTime	PartTime	Volunteer
CompanyPhoneNumber _________________________________________					Averagehoursworkedperweek		____________
CompanyURLInternetAddress____________________________________					Starting Salary	$___________ Per ______
YourPositionTitleandDuties______________________________________					Ending Salary	$___________ Per ______
_______________________________________________________________________					Reason(s)forleaving_____________________
____________________________________________________________________________					________________________________________________
__________________________________________________________________________					________________________________________________
Didyousupervise?			Yes	No Ifyes,howmanyemployees?_____	Maywecontactthisemployer?		Yes	No

StateofHawai‘iDepartmentofHumanResourcesDevelopment

Page 4

FormHRD278(Rev.10/2013)

Question	Answer
Form Name	Form Hrd 278
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	E-MAIL, hrd 278 fillable dlnr, Dismissals, legibly

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