Manoa Cottage Application for Employment
Incomplete information is grounds for not hiring
Return to: Manoa Cottage
Attn: Elizabeth Shim
2035 Kamehameha Ave
Honolulu, Hawaii 96822 Fax: (808) 356-0808
Position you are applying for: / Today’s Date:

Applicant Information

Name (First Middle Last): / Male / Female (circle one)
Date of birth: / SSN: - - / Phone: (home) (cell)
Current address:
City: / State: / ZIP Code:

Education

High School: / Graduate? Y/N : / Location:
CNA/College/Other Education: / Year Graduated:

Work Experience

Employer: / Position: / How long: yrs mos
Dates of employment: / Hourly / Salary (circle one) / Hrs/wk with employer:
Employer address: / Location
Owner/Supervisor: / Phone #: / Can we call for reference? Yes / No
Reason for Leaving:
Employer: / Position: / How long: yrs mos
Dates of employment: / Hourly / Salary (circle one) / Hrs/wk with employer:
Employer address: / Location
Owner/Supervisor: / Phone #: / Can we call for reference? Yes / No
Reason for Leaving:

General Information

Circle all Current Certifications: CNA First Aid CPR 2-StepTB Physical Driver’s License Soc. Sec.
(We will need copies of all certifications to keep on file)
Will Manoa Cottage be your second job? Yes / No / How many hours/week would you like to work?
What date can you start work? / How will you get to work? Drive / Bus / Dropped off (circle)
What is your expected starting pay? $ /hr
Circle the days of the week that correspond to the shift you wish to work:
7am – 3 pm Su M T W Th F Sa
3pm – 11 pm Su M T W Th F Sa
11pm – 7 am Su M T W Th F Sa
Check the one that describes you: ___ I am dependable some of the time.
___ I am dependable most of the time.
___ I am dependable all of the time.
I am able to do the essentials of the job. (initial)______

Other References

Name: / Address: / Phone:

I understand that any job offer is contingent upon my successfully passing a pre-employment drug test. I hearby agree to such pre-employment drug test if requested and authorize the testing facility to release the test results to Manoa Cottage.

Applicant Signature: ______Date: ______