Application

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General Information

Upload Resume

Accepted file types: docx, doc, pdf, Max. file size: 2 MB.

Name

First Middle Last

Sex

Male

Female

Non-Binary

Race: (Check one or more)

White

Black or African American

AmericanIndian or AlaskanNative

Asian

Native Hawaiian or other Pacific Islander

Other

Decline to Answer

Ethnicity: (Check one or more)

Not Hispanic or Latino

Hispanic or Latino

Decline to Answer

Home Phone

Work Phone

Address

Street Address Address Line 2 City State ZIP / Postal Code

Are you at least 16 years of age?

PLEASE READ THOROUGHLY

Have you ever been charged, convicted, plead guilty or nolo contendere to a crime? This includes all misdemeanors (except parking violations) and felonies. Please be sure to disclose any and all convictions, pleas of guilty and pleas of nolo contendere, even if the conviction or plea has been discharged, expunged or otherwise removed from your record.

Yes

State and County of conviction

Date of conviction or plea

MM slash DD slash YYYY

Employment Information

Employment desired

Full-time (40 hrs./wk.)

Part-time

# of hours per week desired

Type

Referred by

Have you ever been employed here before?

Yes

On what date will you be available for work?

MM slash DD slash YYYY

Rate of pay expected

Position applied for

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?

Yes

Have you ever been convicted of mistreatment, neglect or abuse of residents, patients or the misappropriation of their property?

Yes

List other names under which you have been employed

Employment Record

List in order with the most current employment first, include all work history for the past 10 years. Include all military history.

May we contact your past and present employers?

Yes

Why?

Employment History

Name of Company	Your job title	Start date	End date	Reason for leaving	Actions

There are no Entries.

Maximum number of entries reached.

Education

High School/GED Name

High School/GED Address

Choose last year completed

College Name

College Address

Choose last year completed

Graduate School Name

Graduate School Address

Choose last year completed

Vocational, Technical School Name

Vocational, Technical School Address

Years completed

Business, Military, Other

Business, Military, Other Address

Years

Other Experience

If you have had other experience (e.g. volunteer, educational or military) related to the position for which you are applying, please list relevant information below.

Registrations, Licenses, Certifications

Do you have a valid Driver's License?

For positions requiring driving a motor vehicle only

Yes

State

License number

To be completed by registered, licensed, or certified applicants.

State	Current No.	Expiration Date	Actions

There are no Entries.

Maximum number of entries reached.

References

Name

Address

Daytime Phone

Occupation

Name

Address

Daytime Phone

Occupation

Name

Address

Daytime Phone

Occupation

CRIMINAL CONVICTION CERTIFYING STATEMENT

I, , certify by signature below that:

1. I have not been found guilty of abusing, neglecting or mistreating individuals by a court of law;

2. I am not the subject of a pending criminal charge of abusing, neglecting or mistreating individuals; or

3. I have no findings entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property.

I understand that the above listed statements are not limited to the abuse, neglect or mistreatment of a resident or patient, but applies to any individual to whom I was in a responsible or care taker position. Furthermore, as terms of employment I understand that it is my obligation to inform the facility of any pending charges, pleas or convictions involving myself or any other employee of the facility.

Signature

Date

MM slash DD slash YYYY

Informed Consent

For the purpose of compliance with Federal Regulation Vol 56, No. 187; No. 483.13 (c) (1) (ii)(A); I authorize the Bureau of Criminal Apprehension to disclose all information that could relate to criminal charges of abusing, neglecting or mistreating individuals to Towner County Medical Center for the purpose of employment with this healthcare facility.

The expiration of this authorization shall be one year from the date of my signature.

Signature

Date

MM slash DD slash YYYY

HUMAN RESOURCES DEPARTMENT REFERENCE RELEASE

I, , hereby authorize TCMC to contact any schools, former places of employment, credit organizations, law enforcement agencies, and/or other persons who may assist in determining my suitability for employment. I hereby authorize you to provide any information you may make available regarding my job performance and character. Additionally, I release those individuals and/or organizations contacted from all liability, whatsoever, for issuing the requested information.

TCMC may or may not contact any previous or present employers.

May

May not

TCMC may or may not conduct a background check.

May

May not

Signature

Date

MM slash DD slash YYYY

Date of Birth

MM slash DD slash YYYY

(required for background check)

If previous employment has been under another name, please enter your former name here:

Phone

This field is for validation purposes and should be left unchanged.

General Information

Employment Information

Employment Record

Education

Other Experience

Registrations, Licenses, Certifications

References

CRIMINAL CONVICTION CERTIFYING STATEMENT

Informed Consent

HUMAN RESOURCES DEPARTMENT REFERENCE RELEASE

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