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  • Home
  • Providers
  • Services
    • Primary Care
    • Clinic Services
    • Hospital
    • Laboratory & Radiology
    • 24 Hour Emergency
    • Senior Care
    • Outreach Providers
    • Additional Services
  • Facilities
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  • About Us
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    • Board of Directors
    • Ways to Give
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Menu
  • Home
  • Providers
  • Services
    • Primary Care
    • Clinic Services
    • Hospital
    • Laboratory & Radiology
    • 24 Hour Emergency
    • Senior Care
    • Outreach Providers
    • Additional Services
  • Facilities
  • Resources
  • About Us
    • Administration
    • Board of Directors
    • Ways to Give
  • Careers
  • Contact Us
  • MyChart

Application

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General Information

Accepted file types: docx, doc, pdf, Max. file size: 2 MB.
Name
Sex
Race: (Check one or more)
Ethnicity: (Check one or more)
Address
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.
MM slash DD slash YYYY

Employment Information

Employment desired
Have you ever been employed here before?
MM slash DD slash YYYY
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Have you ever been convicted of mistreatment, neglect or abuse of residents, patients or the misappropriation of their property?

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

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Choose last year completed
Choose last year completed

Other Experience

Registrations, Licenses, Certifications

Do you have a valid Driver's License?
For positions requiring driving a motor vehicle only
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References

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.

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.

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.
TCMC may or may not conduct a background check.
MM slash DD slash YYYY
MM slash DD slash YYYY
(required for background check)
This field is for validation purposes and should be left unchanged.

About Us

Towner County Medical Center is your non-profit community hospital. Our team of healthcare workers are committed to providing high-quality healthcare at the lowest possible cost.

Community Health Needs Assessment 2022
Implementation Plan 2022

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  • Primary Care
  • Clinic Services
  • Hospital
  • Laboratory & Radiology
  • 24 Hour Emergency
  • Senior Care
  • Outreach Providers
  • Additional Services

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