* = Required Information

Application for Employment

We are a company, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, medical condition, national origin, marital status or disability with does not prevent performance of essential job duties.

Important Note: Please answer all questions thoroughly to the best of your ability and write legibly.

Emergency Contact:

Yes No
Yes No


Yes No

Which of the following areas can and will you travel to? Check all that apply.


Leeward Downtown Windward Central
North Shore Hawaii Kai Kahuku/Punalu’u East Honolulu



Employment History

(Please go back at least five (5) years and tell us about your work history, Use reverse side of sheet if additional space is required.) Please begin with the most recent employer.

Employment Dates

Employment Dates

Personal References

(Minimum of 2 personal related)

Certification and Release:

I certify that I have read and understood the application form and that the stated and indicated answers to the foregoing questions and statements made by me are complete true in fact and no misrepresentation of me has been made to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of this application and/or discharge at any time during my employment. I authorize Island Pacific Care and/or its’ agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during my employment and that I am not in any way, shape or form at present in the possession or use of illegal drugs and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during my employment.

Employment Agreement Clarification:

This application is not an employment agreement. If I accept an offer of employment, I understand that Island Pacific Care may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that no one, other than an Executive Officer of the Agency has the authority to enter into any employment agreement with terms contrary to the foregoing and then only in writing signed by such officer. I fully understand and accept all the terms and conditions in the above statement.

Island Pacific Care: believes that the information solicited from the applicant is in full compliance with all Federal and State equal employment laws and with the Fair Credit Reporting Act. We do not assume responsibility for the user’s inclusion in this “Application for Employment” of any question which may violate Federal, State or Local Laws and users should consult their own Council with respect to any legal questions concerning the use of this form.

Application Expiration: This application will expire in 60 days. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment in the future by completing a new application.

Security code