Employment Application - Northern Plains Lab

Personal Information

First Name *

Last Name *

Email Address *

Home Phone Number

Cell Phone Number

Present Street Address *

City *

State *

ZIP Code *

Permanent Street Address *

City *

State *

ZIP Code *

Are you prevented from lawfully becoming employed in the United States because of Visa or Immigration Status? *

Yes

No

Required

Proof of citizenship or immigration status will be required upon employment

Are you under 16 yrs of age? *

Yes

No

Required

Are you currently named as a defendant or convicted of a felony or misdemeanor for mistreatment, neglect or abuse of any person, or a misappropriation of property? *

Yes

No

Required

Have you been convicted of any other felony or misdemeanor? *

Yes

No

Required

Please explain:

A criminal conviction record does not by itself constitute an absolute bar to employment. The nature of the conviction will be examined on a case-by-case basis, including subsequent rehabilitation, and will be considered in relation to the responsibilities of the position sought in making each employment decision.

Position Information

Position Applied For *

Available Start Date *

Number of hours *

Have you ever applied to or worked for this company before? *

Yes

No

Required

When?

Under what name?

Reason for leaving

Name of last supervisor at this company

Who referred you to this company?

Employment agency

Newspaper advertisement

Friend

Walk-in

Other (describe below)

NPL Employee referral, first and last name (describe below)

Other/NPL Employee referral, first and last name

Education

High School/GED

Did you graduate?

Yes

No

College/University

Did you graduate?

Yes

No

Degree/Major

Graduation Year

Subjects studied

Additional College/University

Did you graduate?

Yes

No

Degree/Major

Graduation Year

Subjects studied

Trade, business, correspondence school

Did you graduate?

Yes

No

Subjects studied

Specialized training, apprenticeship, and extra-curricular activities that may be helpful in considering your application

Work Experience

Please list your three most recent employment positions, starting with the most recent.

Most Recent Position

Company Name

Job Title

Start Date

End Date

Job Duties and Responsibilities

Supervisor Name

Supervisor Phone

May we contact this employer for a reference?

Yes

No

Reason for Leaving

Employer 2

Company Name

Job Title

Start Date

End Date

Job Duties and Responsibilities

Supervisor Name

Supervisor Phone

May we contact this employer for a reference?

Yes

No

Reason for Leaving

Employer 3

Company Name

Job Title

Start Date

End Date

Job Duties and Responsibilities

Supervisor Name

Supervisor Phone

May we contact this employer for a reference?

Yes

No

Reason for Leaving

References

Please provide three references whom are not related to you or previous employers and have known for at least one year.

Reference 1

Full Name

Address and Phone Number

Relationship to You

Years Known

Reference 2

Full Name

Address and Phone Number

Relationship to You

Years Known

Reference 3

Full Name

Address and Phone Number

Relationship to You

Years Known

Licensure Information

For positions requiring a professional license, list the license name, number and expiration date

Are you licensed in North Dakota?

Yes

No

If not, have you applied for licensure?

Yes

No

When?

AUTHORIZATION AND AGREEMENT

Please read before signing

I hereby certify that this application contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any such misrepresentation or falsification, my application will be rejected and I may be removed from the job after appointment. I understand that under Title VII of the Civil Rights Act of 1964 and the North Dakota Human Rights Act, I cannot be discriminated against in employment, including consideration for promotion, for reason of race, color, religion, national origin, sex, or on the basis of age, physical or mental disability, or status as a protected veteran. I further understand that this employment application and other employment related documents I may have been furnished are not contracts of employment; also, that any oral or written statements to the contrary are hereby expressly disavowed. The employer has my authorization to thoroughly investigate my work, criminal and personal history which is job related. I certify that I will hold no person, corporation or organization liable for giving or receiving information in this investigation. I further understand that if I am employed, such employment is for an indefinite period of time, that either I or NPL can terminate such employment at anytime, and that NPL can change wages, benefits and conditions at anytime. *

Signature *

Release: Having made application for employment with NPL and desiring them to be informed as to my previous record and character, I hereby authorize NPL to investigate my past record and to ascertain any and all information which may concern my record and character, whether same is of record or not, and release my present and past employers, references, and all persons whomsoever from any damage because of furnishing said information.

Signature *

NPL provides an orientation period, which allows NPL to review you and your adjustment to your new position. During this orientation period, you and your supervisors have the freedom to terminate your employment at NPL without notice. NPL operates continuously and you are expected to perform services in accordance with your job description and approved work schedule. Thank you for completing this application form and for your interest in employment with Northern Plains Laboratory. We assure you that your opportunity for employment will be based only on your merit, employment history, and academic background.

To comply with EEO record keeping and other legal requirements, we request that you complete the following data information questionnaires. Completion of the questionnaires is completely voluntary and refusal to complete this information will not subject an applicant or employee to adverse treatment. This information will not be used as part of the hiring process and will not be shared with any employees who have responsibility for making hiring decisions. Please email completed forms to the Equal Opportunity Manager at whitney.paul901@commonspirit.org

Click here for Equal Employment form

I have been given the opportunity to complete the Voluntary EEO Self-identification form

Click here to view Voluntary-Self-Id-Disability-form-HR305

I have been given the opportunity to complete the Voluntary Self-identification of Disability form

Click here for Self ID Vet Pre offer

I have been given the opportunity to complete the Voluntary Self-identification Protected Veteran Pre-offer form