Date of Application: ________________
GENERAL INFORMATION
NAME:________________________ TELEPHONE: (____)_________________(LAST, FIRST, MIDDLE)

ADDRESS: _______________________________________________________ARE YOU LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES?
YESNOARE YOU EMPLOYED NOW?
YESNO
WHERE?________________________________________________________IF SO, MAY WE INQUIRE WITH YOUR PRESENT EMPLOYER?
YESNOHAVE YOU EVER APPLIED TO THIS COMPANY BEFORE?

YESNO

WHERE? ___________________ WHEN?___________________HAVE YOU EVER BEEN EMPLOYED BY THIS COMPANY BEFORE?
WHERE? ___________________ WHEN?___________________EMPLOYMENT DESIREDPOSITION(S): 1. ________________________________________
2. ________________________________________DATE YOU CAN START: __________________________________AVAILABILITY (DAYS AND HOURS AVAILABLE TO WORK)MONDAYTUESDAYWEDNESDAY

THURSDAYFRIDAYSATURDAYTIME
FROMTIMETOARE YOU AVAILABLE TO WORK ON EVENINGS?
HOLIDAYS?

YESYESNONO

59-864 Kamehameha Hwy. Haleiwa, HI 96712
Phone: (808) 638-7766 Fax: (808) 638-7776 www.waimeavalley.net

SUNDAYSKILLS
LIST ALL JOB RELATED CERTIFICATIONS AND SKILLS INCLUDING, IF
APPLICABLE, ALL COMPUTER PROGRAMS/SOFTWARE YOU CURRENTLY USE:________________________________________________________________________________________________________________________________ARE YOU OPEN TO PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION(S)FOR WHICH YOU ARE APPLYING, WITH OR WITHOUT A REASONABLE
ACCOMMODATION? [REFER TO JOB DESCRIPTION BEFORE RESPONDING]YESNOEMPLOYER:______________________________ EMPLOYED FROM: _________ TO: _________ADDRESS: _______________________________JOB TITLE: ______________________ SUPERVISOR: __________________________________WORK PERFORMED: _____________________________________________________________REASON FOR LEAVING:___________________________________________________________EMPLOYER:______________________________ EMPLOYED FROM: _________ TO: _________ADDRESS: _______________________________JOB TITLE: ______________________ SUPERVISOR: __________________________________WORK PERFORMED: _____________________________________________________________REASON FOR LEAVING:___________________________________________________________EMPLOYER:______________________________ EMPLOYED FROM: _________ TO: _________ADDRESS: _______________________________JOB TITLE: ______________________ SUPERVISOR: __________________________________WORK PERFORMED: _____________________________________________________________REASON FOR LEAVING:___________________________________________________________59-864 Kamehameha Hwy. Haleiwa, HI 96712
Phone: (808) 638-7766 Fax: (808) 638-7776 www.waimeavalley.net

EDUCATIONName of School

Location

Years
CompletedDid YouGraduate?

GRAMMAR SCHOOLHIGH SCHOOLCOLLEGE

OTHER

OTHER
DO YOU KNOW ANYONE PRESENTLY WORKING FOR THIS COMPANY?
YESNO

IF SO, WHO?
________________________________________________________________
CERTIFICATION (READ CAREFULLY BEFORE SIGNING)
I certify that all statements made on this application are true and complete to the best of myknowledge. I understand and agree that any misrepresentation or omission of material fact issufficient ground for cancellation of this application, or if I am employed by Hi’ipaka LLC (the“Company”), for immediate discharge from employment.
Except as may be noted above, I authorize the Company to contact and obtain information fromall reference, employers and educational institutions listed, and to investigate any of the above
information for purposes of verification. I also authorize the Company, if I receive a conditional
offer of employment, to conduct an inquiry into my criminal conviction record for the past tenyears (excluding periods of incarceration), including state and federal checks, to the extent
permitted by law.
I hereby agree to hold the Company and its representatives harmless and release them fromliability of any kind for any statements, acts or omissions in the course and/or as a result of its
investigations in connection with this application.
I also understand that if employed, I will be employed on an at-will basis and that my employment
may be terminated at any time, either by me or by the Company, with or without cause.
___________________DATE________________________________
SIGNATURE OF APPLICANT

59-864 Kamehameha Hwy. Haleiwa, HI 96712
Phone: (808) 638-7766 Fax: (808) 638-7776 www.waimeavalley.net

Degree(s)