Form Preview Example

ATTACHMENT C

STATE OF HAWAII

APPLICATION FORM FOR NON-CIVIL SERVICE TEMPORARY APPOINTMENT OUTSIDE OF LIST (TAOL) POSITIONS

GENERAL INSTRUCTIONS: Please type or print legibly in ink.

The information you provide will be used to determine whether you are eligible for the position for which you are applying.

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.

Your application and accompanying material are confidential and becomes the property of the department considering you for the TAOL appointment. Please make your own copy of your application before submitting it.

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.

1.CITIZENSHIPSTATUS.Placeacheckmarkintheappropriateblock:

A.		Citizen of the U.S.
B.		National of the U.S.
B.		National of the U.S.
C.		Permanent Resident Alien of the U.S.
C.		Permanent Resident Alien of the U.S.
D.		Other – Non-citizen of the U.S.
D.		Other – Non-citizen of the U.S.
	Are you authorized under federal law to work in the U.S. without restrictions?
			Yes	No Type ofVisa ________________________

2.RESIDENCESTATUS.Checktheappropriateblockandfillinthespaces:

Are you a current or former legal resident of Hawai‘i?		Yes			No
Month/year Hawai‘iresidencebegan: from	/		to	/
Period(mo./yr.)offormerlegalresidency:from	/		to	/

(NOTE:Statelawrequiresmostapplicantstobelegalresidentsorformer legalresidentsofHawai‘i.Ifyouareindoubtaboutyourstatus,please complete and submit Form 319 with this application.)

3.UNITEDSTATESMILITARYSERVICE.

Veterans Preference I claim			5 points		10 points (preference)
Veterans Preference I claim			5 points		10 points (preference)
Serial or Service No.: __________________________________
Date Entered Service:	__________________________________
Date Separated Service: __________________________________
Type of Last Separation:		Honorable		Other than honorable
Type of Last Separation:		Honorable		Other than honorable

5pointsveterans preference may be awarded to honorably separated veterans who served on active duty in the U.S. Armed Forces:

A. During the period December 7, 1941 to July 1, 1955;

B. For more than 180 consecutive days from Jan. 31, 1955 through Oct. 14, 1976 (Not including initial active duty for training under Reserve or National Guard programs);

C. In a campaign or expedition for which a campaign badge or service medal was authorized.

10pointsveterans preference may be awarded to:

A. Honorably separated veterans with service-oriented disability; including those awarded the Purple Heart;

B. The spouse of an honorably separated veteran with a service- connected disability which disqualifies the veteran for State positions in his/her usual occupation.

C. An unmarried, supervising spouse of a person who died while on active duty, or of an honorably separated veteran who served during the periods cited above.

To receive 5 points, you must submit a copy of your DD-214 showing dates of honorable service with this application. To receive 10 points, you must submit an official statement from the Veterans Administration or armed service dated within the past 12 months which confirms your qualification to receive 10 points preference. Spouses or widows must also submit evidence of marriage, and, as applicable, veteran’s death.

JOB TITLE(S) APPLYING FOR

5.Temporary Appointment Outside of List (TAOL)

RECRUITMENT NUMBER

6.NAME:

First

Middle

Last

MAILING

7. ADDRESS:

Number or P.O. Box

Street

City

State

Zip Code

PHONE

8. NUMBER:

BusinessHome

SOCIAL

SECURITY

9.NUMBER:

10.CERTIFICATE OFAPPLICANT

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 mate- rial 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 applica- tion and understand that there may be additional em- ployment-related tests as required.

Date	Original Signature of Applicant

State of Hawai‘i Departmental Application for TAOL Positions

Page 1

Form HRD 315/TAOL (Rev. 11/2003)

Information requested in items 11 through 15 is needed to make determinations on your suitability for employment. Convictions, dismissals from EDUCATION: When verification is required as indicated in the “Departmental Competitive Announcement,” required documentation must be submitted employment or dishonorable separations from military service do not automatically disqualify you for employment. The circumstances of each at the time of application. If not, you may not receive credit for the training and/or your application may be considered incomplete and rejected. The individual case will be evaluated against the requirements of the position for which you have applied, to determine suitability for employment. The information you provide in this section will be used strictly in the evaluation of your qualifications for the job(s) for which you are applying. information on this page will not be released to persons involved in the appointment process.

11.DISMISSALS FROM EMPLOYMENT AND/OR DISHONORABLE SEPARATIONS FROM MILITARY SERVICE

Within the past five years, were you:

a)Fired, terminated for cause, dismissed, discharged or asked to resign from employment?

b)Separated from military service under conditions other than honorable? ...................................................

(If you answer “Yes” to question 11a or 11b, please indicate in item #15 below, the date 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.)

	12. CONVICTION FOR A VIOLATION OF LAW
	A. Have you been convicted of a violation of law? NOTE: In answering this question,	.........................
	you need NOT report the following:	.........................
	you need NOT report the following:

YES	NO
YES	NO

YES........... NO

(1) Arrests not followed by convictions;

(2) Convictions which were annulled or expunged;

(3) Offenses for which you were tried as a minor or juvenile;

(4) Convictions of penal offenses for which only fines and no jail sentences may be imposed;

(5) Convictions of misdemeanor in which the period of 20 years has elapsed since the date the sentence was fulfilled and during which elapsed time there has not been any subsequent arrest or conviction.

B. Have you ever been convicted of any act, attempt, or conspiracy to overthrow the	YES	NO
State or federal government by force or violence?	YES	NO
State or federal government by force or violence?	........................
(If you answer “Yes” to question 12A or 12B, please indicate in item #15 below,
the dates, nature and circumstances of the conviction; the sentence imposed and
its current status; and any other relevent information you wish to provide.)
13. SUSPENSION OR REVOCATION OF LICENSE
Was your license or certification to practice in a regulated profession (for example,	YES	NO
physician, engineer, nurse, plumber, etc.) ever suspended or revoked?	YES	NO
(If you answer “Yes,” please indicate in item #15 below, the type of license; the
date; the state; the specific board or organization that suspended or revoked your
license; the circumstances of the suspension or revocation; and any other rel-
evant information you wish to provide.)
14. SETTLEMENTS OR AGREEMENTS
Have you accepted a settlement, a cash buyout such as through the State’s Separation Incentive
Program, or, have any restrictions that you would not seek further employment with the	YES	NO
State of Hawaii?		NO

15. USE THIS SPACE TO EXPLAIN ANY “YES” ANSWERS TO THE QUESTIONS ABOVE.

State of Hawai‘i Departmental Application for TAOL Positions

Page 2

Form HRD 315/TAOL (Rev. 11/2003)

EMPLOYMENT AND EDUCATION HISTORY

1.RECRUITMENTNUMBER:

T A O L

(TemporaryAppointment Outside of List)

The information you provide will be used to determine whether you meet pub- lic employment requirements and the minimum qualification requirements in the Class Specifications. Federal laws (Title VII of the Civil Rights Act of 1964, the Civil Rights Act of 1991, and the Americans with Disabilities Act) prohibit employers from discriminating on the basis of race, color, religion, sex, national origin, or disability. The Age Discrimination in Employment Act prohibits discrimination on the basis of age. Chapter 378, H.R.S., prohibits employers from discriminating on the basis of race, sex, sexual orientation, age, religion, color, ancestry, disability, marital status, or arrest and court record except where it is a bona fide occupational qualification. The federal laws ap- ply to all forms of employment decisions and actions, including pre-employ- ment inquiries. The State of Hawaii is an equal opportunity employer and com- plies with applicable state and federal laws relating to employment practices.

2.JOBTITLE(S)

3.NAME:

First

Middle

Last

Other names used

(includingmaidenname)

	MAILING
4.ADDRESS:
	Number or P.O. Box		Street

	City	State	Zip Code
5. PHONENO.:
	Business		Home

6.SOCIALSECURITYNUMBER:

7.EDUCATION:Whenverificationisrequired,thedocumentationmustbesubmittedatthetimeoftheapplication. Ifnot,youmaynotreceivecredit forthetrainingand/oryourapplicationmaybeconsideredincompleteandrejected. Theinformationyouprovideinthissectionwillbeusedstrictlyin the evaluation of your qualifications for the position for which you are applying.

A.Name and location of last grade school attended:	Highest Grade Level	Date of
(elementary, intermediate or high school)	Completed	Graduation

DO NOT WRITE IN THIS SPACE

B.In-service training, business, trade, armed forces, colleges or university, graduate of professional schools

NAME & ADDRESS

Course or Major	Number of Credits		Kind of Degree,	Date
Field of Study	or Hours Completed		Diploma or Certificate	Received
	Sem’tr	Quarter	Received

8.OTHERQUALIFICATIONS

A. LICENSE OR CERTIFICATE: Please indicate the kind, registration number, and the State or other licensing authority. If proof of evidence is required,pleasesubmitacopyorpresentforverification.

B. KNOWLEDGE OF LANGUAGE OTHER THAN ENGLISH: List the language and check the appropriate block(s). Some positions require theabilitytospeak,read,and/orwriteinalanguageotherthanEnglish.

C.SPECIALQUALIFICATIONS:Includemembershipinprofessional orscientificsocieties,honors,awards,fellowships,publications(list but do not submit unless requested), etc.

LANGUAGE

SPEAK READ WRITE

State of Hawai‘i Departmental Application for TAOL Positions

Page 3

Form HRD 315/TAOL (Rev. 11/2003)

9.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 types of employees you supervised. If more space is needed provide the information on a blank sheet titled “Experi- ence” and attach it to this form. Your answers may be verified with former employers.

Please complete this section even if you are attaching a resume or other attachments.

YOUR PRESENT OR LAST POSITION

Employer _____________________________________________________		From: _________________________________
		From: _________________________________
Address _______________________________________________________			Month	Year
		To: ____________________________________
_____________________________________________________________		To: ____________________________________
			Month	Year
Name and Title of Your Supervisor _________________________________		Full Time	Part Time	Volunteer
		Average hours worked per week		____________
Your Title _____________________________________________________		Average hours worked per week		____________

Duties and Responsibilities ________________________________________		Starting Salary	$___________ Per ______

_______________________________________________________________		Ending Salary	$___________ Per ______
______________________________________________________________		Reason(s) for leaving _____________________
______________________________________________________________	________________________________________________
___________________________________________________________________________________________________________________	________________________________________________
_______________________________________________________________________________________________________________________	_____________________________________________
Employer _____________________________________________________		From: _________________________________



Address _______________________________________________________			Month	Year
		To: ____________________________________
_____________________________________________________________		To: ____________________________________
			Month	Year
			Month	Year
Name and Title of Your Supervisor _________________________________		Full Time	Part Time	Volunteer
		Average hours worked per week		____________
Your Title _____________________________________________________		Average hours worked per week		____________

Duties and Responsibilities ________________________________________		Starting Salary	$___________ Per ______

_______________________________________________________________		Ending Salary	$___________ Per ______
______________________________________________________________		Reason(s) for leaving _____________________
______________________________________________________________	________________________________________________
___________________________________________________________________________________________________________________	________________________________________________
Employer _____________________________________________________		From: _________________________________
		From: _________________________________
Address _______________________________________________________			Month	Year
		To: ____________________________________
_____________________________________________________________		To: ____________________________________
			Month	Year
			Month	Year
Name and Title of Your Supervisor _________________________________		Full Time	Part Time	Volunteer
		Average hours worked per week		____________
Your Title _____________________________________________________		Average hours worked per week		____________

Duties and Responsibilities ________________________________________		Starting Salary	$___________ Per ______

_______________________________________________________________		Ending Salary	$___________ Per ______
______________________________________________________________		Reason(s) for leaving _____________________
______________________________________________________________	________________________________________________
___________________________________________________________________________________________________________________	________________________________________________
Employer _____________________________________________________		From: _________________________________


Address _______________________________________________________			Month	Year
		To: ____________________________________
_____________________________________________________________		To: ____________________________________
			Month	Year
			Month	Year
Name and Title of Your Supervisor _________________________________		Full Time	Part Time	Volunteer
		Average hours worked per week		____________
Your Title _____________________________________________________		Average hours worked per week		____________

Duties and Responsibilities ________________________________________		Starting Salary	$___________ Per ______

_______________________________________________________________		Ending Salary	$___________ Per ______
______________________________________________________________		Reason(s) for leaving _____________________
______________________________________________________________		________________________________________________
___________________________________________________________________________________________________________________		________________________________________________

State of Hawai‘i Departmental Application for TAOL Positions	Page 4	Form HRD 315/TAOL (Rev. 11/2003)
	Page 4

Question	Answer
Form Name	Form Hrd 315 Taol
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	0300001attc hawaii civil service form 4

Form Hrd 315 Taol – Fill Out and Use This PDF

Form Hrd 315 Taol PDF Details

Form Preview Example

Form Hrd 315 Taol isn’t the one you’re looking for?

Form Hrd 315 Taol – Fill Out and Use This PDF

Form Hrd 315 Taol PDF Details

Form Preview Example

Form Hrd 315 Taol isn’t the one you’re looking for?

Related Documents