Personal Information
Mailing Address
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Physical Address
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Secondary Phone
Other Contact Number
Are you a US citizen? *If no, please provide documentation
Employment Desired
If Nursing, please Specify
Education/Training
Highest Completed Level of Education
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Name and Address of School
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Courses Taken
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Diploma, Degree or certificate received
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Other Degrees/Training/Classes
Are you claiming Tribal Preference?
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If yes, with which tribe?
IF you claim tribal preference for the hiring process, additional documentation of tribal enrollment WILL be required.
Relevant Extra Curricular Activities while in school
Area of specialization or major interest
Professional organization membership, honors received, volunteer or community service, specialized training, or other qualifications you have which you feel are related to the position for which you are applying:
Professional Licenses and/or Certifications
Type
Organization or State Issued
Number
Date Issued
Type
Organization or State Issued
Number
Date Issued
Military Record
Branch
Entry Rank
Separation Rank
Separation Date
Military Occupation/Speciality
Employment History - References
List current (or most recent) employer first and all others in reverse chronological order. Please List 1) Company Name, Address, 2) Position, 3) Job Description and Responsibilities, 4) Reason for leaving, 5) Dates employed, 6) Phone Number, 7) Starting and Ending Salary, and 8) Direct Supervisor name, for each job. We will be calling these jobs for references.
Job 1:
Job 2:
Job 3:
Non-Employer References
Please list 3 references who are NOT relatives or former employers. Please list Name and relationship, title, company name and address and Phone number for each reference.
Reference 1:
Reference 2:
Reference 3:
Have you ever had any traffic violations?
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If yes, when and where?
Have you ever been convicted of a crime?
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If yes, for what, when, and where?
Have you ever been convicted of a felony and/or misdemeanor?
Conviction of a criminal offense will not necessarily jeopardize employment
Have you ever had disciplinary action taken against any license, registration, certificate or permit you now or previously held (This includes but is not limited to final orders, suspension, revocation, denial, cease and desist order, etc.)?
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If yes, please explain
How did you hear about this opportunity?
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This business does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, veteran status, sexual orientation, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.
I voluntarily give this business the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information.
I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.
If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.
I understand that a criminal background check and driving record check will be conducted prior to employment.
By signing below I recognize that my digital signature is subject to all the same consequences as a physical signature.
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Date Completed
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