S TAT E O F H A W A I ‘ I A P P L I C AT I O N
FOR NON-CIVIL SERVICE APPOINTMENT
DEPARTMENT OF LAND & NATURALRESOURCES
Personnel Office, Room 231
1151 Punchbowl Street, Honolulu, Hawaii 96813

FOR OFFICIAL USE ONLY
DEPARTMENTAL PERSONNEL STAFF
TO SELECT CATEGORY.

Exempt89 DayTAOL___________RECEIVED DATE/TIME STAMPGENERAL 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.

1.

8. WORK AUTHORIZATION
Please answer both A and B below:
A. Are you legally authorized to work in the UnitedStates? Yes
No

POSITION TITLE APPLYING FOR

2.

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

RECRUITMENT NUMBER or POSITION NUMBER

3. NAME:
Last

First

Middle9. NOTICE OF “AT WILL” EMPLOYMENTOTHER NAMESUSED OR FORMER
4.
LAST NAME:

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 fromyour employment at the prerogative of the department head ordesignee at any time.

MAILING

5. ADDRESS:

P.O. Box

Cityor

Number and Street

State

Zip Code

E-MAIL

6. ADDRESS:CERTIFICATE OF APPLICANT
I have been informed and understand that this application is forconsideration 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 aretrue and correct to the best of my knowledge, and I agree andunderstand 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.

PHONE

7. NUMBER:
Home

Other

Date

State of Hawai‘i Department of Human Resources Development

Page 1

Original Signature of Applicant

Form HRD 278 (Rev. 7/2020)

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.

Information requested in items 10 through 19 is needed to make determinations on your suitability for employment. Dismissals
from employment or dishonorable separations from military service do not automatically disqualify you from employment.
The circumstances of each individual case will be evaluated against the requirements of the position for which you haveapplied, to determine suitability for employment.
10. 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?............... YES..... NOB) Separated from military service under conditions other than honorable? ....................................... YES..... NO(If you answer “Yes” to question 10A or 10B, please explain in detail in item #11 below, the dates andreasons 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. WITHIN THE PAST THREE (3) YEARS, HAVE YOU BEEN CONVICTED OF ANY
OFFENSE RELATED TO CONTROLLED SUBSTANCES? .............................................................. YES.....
(If you answer “Yes” to the above question, please explain in detail in item #13 below, the dates,
nature and circumstances of the conviction; the sentence imposed and its current status; and any otherrelevant information you wish to provide.)
13. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
14. HAVE YOU EVER BEEN CONVICTED OF ANY ACT, ATTEMPT OR CONSPIRACY TO
OVERTHROW THE STATE OR FEDERAL GOVERNMENT BY FORCE OR VIOLENCE? ....... YES .....
(If you answer “Yes” to the above question, please explain in detail in item #15 below, the dates,
nature and circumstances of the conviction; the sentence imposed and its current status; and any otherrelevant information you wish to provide.)
15. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
16. SUSPENSION OR REVOCATION OF LICENSE
Was your license or certification to practice in a regulated profession (for example,
physician, engineer, nurse, plumber, etc.) ever suspended or revoked? ..................................................... YES.....
(If you answer “Yes,” please explain in detail in item #17 below, the type of license; the date; the state; the specificboard 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. SETTLEMENTS OR AGREEMENTS
Have you accepted a settlement, a cash buyout such as through the State’s Separation Incentive Program
or are you subject to any restriction limiting or precluding you from seeking or securing employment
with the State of Hawai‘i? ....................................................................................................................... YES.....
(If you answer “Yes,” to question 18, please explain in detail in item #19 below, the reason and date of your settlement
or restriction from applying with the State of Hawai‘i.)19._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

State of Hawai‘i Department of Human Resources Development

Page 2

NO

NO

NO

NO

Form HRD 278 (Rev. 7/2020)

STATE OF HAWAI‘I DEPARTMENT OF LAND & NATURAL RESOURCESEDUCATION AND EMPLOYMENT HISTORYSTATE OF HAWAI‘I APPLICATION FOR NON-CIVIL SERVICE APPOINTMENTFOR OFFICIAL USE ONLY
DEPARTMENTAL PERSONNEL
STAFF TO SELECT CATEGORY

Exempt89 Day1. POSITION TITLE APPLYING FOR:
2. RECRUITMENT NUMBER or POSITION NUMBER:

As required by federal and/or state laws, we do not discriminate

3. NAME:on the basis of age, sex (including gender identity or

4. OTHER NAMES

expression), religion, race, color, ancestry, national origin,

USED OR FORMERLAST NAME:

disability, marital status, veteran’s status, sexual orientation,

5.

E-MAILADDRESS:

6.

MAILINGADDRESS:arrest and court record, citizenship, genetic information or any

Lastother protected characteristic. The State of Hawai‘i is an equal

First

P.O. Boxor

TAOL_________

MiddleNumber and Street

opportunity employer and complies with applicable state andCityfederal laws relating to employment practices.

State

Zip Code

7. PHONE NO.:
Home

Other

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 ofyour qualifications for the position(s) for which you are applying. The information you submit on this form may be verified.

DO NOTWRITE
IN THISSPACE

A. NAME AND 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-service training, business, trade, armed forces, college or university, graduate of professional schools.
Course or Major
Field of StudyNAME & ADDRESS

Number of Credits
or Hours CompletedSemesterQuarter

Kind of Degree,
Diploma or Certificate
Received

9. LICENSES, CERTIFICATES, OTHER QUALIFICATIONS
A. DRIVER’S LICENSE:

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 requirea driver’s license.

B. OTHER LICENSES OR CERTIFICATES: Please indicate the kind, registration number, and the State or other licensing authority. If proof ofevidence is required, please submit a photocopy or present for verification.

C. KNOWLEDGE OF LANGUAGE OTHER THAN ENGLISH: List thelanguage and check the appropriate block(s). Some positions require the ability
to speak, read, and/or write in a language other than English.
LANGUAGE

SPEAK

READ

State of Hawai‘i Department of Human Resources Development

D. SPECIAL QUALIFICATIONS: Include membership in professionalor scientific societies, honors, awards, fellowships, publications (list but
do not submit unless requested), etc.

WRITE

Page 3Form HRD 278 (Rev. 7/2020)

EDUCATION AND EMPLOYMENT HISTORYSTATE OF HAWAI‘I APPLICATION FOR NON-CIVIL SERVICE APPOINTMENTYour Present or Last Position

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 forthe same employer. To receive full credit for your experience, describe in detail the tasks you were assigned. If you supervised others, explain yourduties 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.

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?_____

From: _________________________________

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?_____

From: _________________________________

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?_____
State of Hawai‘i Department of Human Resources Development

Page 4

Month

Year

To: ____________________________________
Month

Full Time

Year

PartTime

Volunteer

Average hours worked per week ____________
Reason(s) for leaving ____________________________________________________________________________________________________________________________________________________________________________________________________________________
May we contact this employer?

Month

Yes

No

Year

To: ____________________________________
Month

Full Time

Year

PartTime

Volunteer

Average hours worked per week ____________
Reason(s) for leaving ____________________________________________________________________________________________________________________________________________________________________________________________________________________
May we contact this employer?

Yes

No

From: _________________________________
Month

Year

To: ____________________________________
Month

Full Time

Year

PartTime

Volunteer

Average hours worked per week ____________
Reason(s) for leaving ____________________________________________________________________________________________________________________________________________________________________________________________________________________
May we contact this employer?

Yes

No

From: _________________________________
Month

Year

To: ____________________________________
Month

Full Time

Year

Part Time

Volunteer

Average hours worked per week ____________
Reason(s) for leaving ____________________________________________________________________________________________________________________________________________________________________________________________________________________
May we contact this employer?
YesNo
Form HRD 278 (Rev. 7/2020)