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APPLICATION FOR EMPLOYMENT
NORTHERN HILLS TRAINING CENTER
625 Harvard Street
Spearfish, SD 57783-1897
Prospective employees will receive consideration without discrimination for race, creed, color, sex, age, national origin, handicap, or veteran status.

PERSONAL

  
Last Name
First Name
Middle
Street Address/P.O. Box
City
State
Zip
Home Phone
Email Address
Social Security #
Have you ever applied for employment with us? Yes No
If yes: Month Location  
How did you hear about the position?
Position Desired
Pay Expected
Apart from absence for religious observance, are you available for full-time work? Yes No
If not, what hours can you work?
Will you work overtime if asked? Yes No
Are you legally eligible for employment in the United States? Yes No
When will you be available to begin work?
Other special training or skills (languages, machine operation, etc.)  

 

EDUCATION

          
School Name and Location
of Schoot		 Course of Study No. of Yrs
Completed		 Did You
Graduate?		 Degree of
Diploma
Graduate Yes No
College Yes No
Business/Trade/Technical Yes No
High School Yes No
Elementary Yes No

 

 

Membership in Professional or Civic Organizations
(Exclude those which may disclose your race, color, creed, sex, sexual orientation, age, ethnic or national origin, marital status, disability, or veteran status.)

 

EMPLOYMENT HISTORY

 Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.
  Company Name
Address
Telephone
Employed From: To:
Name of Supervisor
Weekly Pay Start: Last:
State Job Title and Describe Your Work (175 characters Max)
 Exceeded maximum number of characters.
Reason for Leaving (150 characters Max)
   Exceeded maximum number of characters.
 
Company Name
Address
Telephone
Employed From: To:
Name of Supervisor
Weekly Pay Start: Last:
State Job Title and Describe Your Work (175 characters Max)
 Exceeded maximum number of characters.
Reason for Leaving (150 characters Max)
   Exceeded maximum number of characters.
 
Company Name
Address
Telephone
Employed From: To:
Name of Supervisor
Weekly Pay Start: Last:
State Job Title and Describe Your Work (175 characters Max)
 Exceeded maximum number of characters.
Reason for Leaving (150 characters Max)
   Exceeded maximum number of characters.
 
  Company Name
Address
Telephone
Employed From: To:
Name of Supervisor
Weekly Pay Start: Last:
State Job Title and Describe Your Work (175 characters Max)
 Exceeded maximum number of characters.
Reason for Leaving (150 characters Max)
   Exceeded maximum number of characters.

REFERRENCES

 List two (2) professional and one (1) personal reference we may contact.
  Name Title Address Telephone
1.
2.
3.

 

GENERAL INFORMATION
Do you have a valid Driver’s License? Yes No
If Yes - what state?  
If No - explain: (Max 125 characters)
 Exceeded maximum number of characters.
Do you have motor vehicle insurance? Yes No
Have you had any motor vehicle violations within the past seven (7) years? Yes No
If Yes - describe in full: (Max 125 characters)
 Exceeded maximum number of characters.
Have you ever been bonded? Yes No
If Yes - with what employers? (Max 125 characters)
 Exceeded maximum number of characters.
Have you been convicted of any crime (felony or misdemeanor) or a vehicle violation, such as a DWI, in the past 12 years? Yes No
If Yes - describe in full: (Max 125 characters)
 Exceeded maximum number of characters.
Do you have a conviction or prior employment history of abuse, neglect or mistreatment? Yes No
If Yes - describe in full: (Max 125 characters)
List names of relatives and friends working for us: (Max 125 characters)    
Write a short narrative explaining the skills and qualities which you have that will enable you to be a valuable employee.
(Max 125 characters)
 Exceeded maximum number of characters.

 

SIGNATURE
(NHTC will hold your application on file for 60 days unless notified by you to withdraw your application from consideration.) The undersigned hereby authorizes any state department of social services, any police department, and the Northern Hills Training Center to obtain and/or release any and all information regarding the social services, work, credit, or criminal history of the undersigned applicant for consideration of employment by the Northern Hills Training Center. The undersigned also understands that misrepresentation or omission of facts called for in this application is cause for cancellation of the application and/or separation of employment. “I Attest: The information provided in this Application for Employment is true, correct, and complete. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.”
You must agree to this before proceeding. I AGREE  
   

BACKGROUND INVESTIGATION

  
The Northern Hills Training Center will complete a Criminal Background Investigation on all prospective employees. The Northern Hills Training Center will utilize the State Court Administrator’s Office in conducting all Criminal Background Investigations. Other investigations may be conducted by the Nurse’s Aide/Teacher Registry and the Sex Offender Registry. Northern Hills Training Center may make an offer of employment to a prospective employee contingent upon the results of the Criminal Background Investigation. The Northern Hills Training Center shall withdraw its offer of employment if the report reveals a disqualifying record. A disqualifying record is defined in Policy Memorandum #02-03 - Exclusion of Certain Individuals and Entities from Participation in Medicare and State Health Care Programs. Employees will be automatically disqualified for: 1. Any felony crime conviction, 2. Any conviction of a crime against a person causing bodily harm, including abuse, neglect, assault, etc., 3. Any other conviction of a crime. Circumstances to consider include: number of convictions, length of time since the conviction, and the severity of the crime. I understand this as a condition of employment. I have read, had the opportunity to ask questions, and understand the above.

You must agree to this before proceeding.I AGREE
   

NORTHERN HILLS TRAINING CENTERPARTIAL

CONDITIONS OF EMPLOYMENT

 
I UNDERSTAND AND AGREE THAT: It is my understanding that Northern Hills Training Center (NHTC) may make a thorough review of my experience and education and may verify all application and/or oral interview materials. I authorize such review and the giving and receiving of any information, requested by NHTC. I release from liability any person giving or receiving such information. Falsification, misrepresentation, or omission of facts so given, or other derogatory information discovered as a result of this review may prevent my being hired, or if hired, may subject me to immediate dismissal. Although the NHTC makes every effort to accommodate employee preferences, the needs of persons served by the NHTC may at times, make the following conditions mandatory: overtime, shift work, holidays, a rotating schedule, and/or a work schedule other than which I may have hired for. I understand and accept these conditions of my future or continuing employment. I understand that If I am employed, I am employed for an indefinite period of time and the NHTC may change wages, benefits, and conditions of my employment at any time. In consideration for EMPLOYMENT and by being considered for employment by the NHTC, I agree to follow the policies, rules and regulations of the NHTC, and acknowledge that these policies, rules and regulations may be changed, interpreted, withdrawn, or added to by the NHTC at any time, at its discretion, and without any prior notice to me. I further acknowledge that my employment may be ended per personnel policies. I understand that representatives of the NHTC do not have the authority to enter into any agreement for employment for any specified period of time. Further, no representative of the NHTC may guarantee other personnel moves either prior to commencement of employment or after I have become employed. Assurances of any benefits or terms and conditions of employment, or any agreement contrary to the foregoing, may not be entered into. The NHTC reserves the right, due to Federal Medicaid Regulations and other state and federal laws, to complete criminal records, Department of Human Services, Motor Vehicle, and other eligibility for employment checks on all applications and employees. I understand that Northern Hills Training Center is a Drug and Alcohol-Free Workplace and that I will be submitted to random drug/alcohol testing per NHTC policy. I understand that the position I am applying for (if involving direct service responsibilities) may involve implementing crisis prevention and intervention services which may include lifting, pulling and guiding persons with disabilities against potential resistance. I understand this as a condition of employment and have no reason to believe I cannot implement these or other responsibilities of the position for which I am applying. I have read, had the opportunity to ask questions, and understand the above.

You must agree to this before proceeding.I AGREE

PROSPECTIVE EMPLOYEES SHALL RECEIVE CONSIDERATION WITHOUT DIS-CRIMINATION BECAUSE OF RACE, COLOR, CREED, SEX, SEXUAL ORIENTATION, AGE, ETHNIC OR NATIONAL ORIGIN, MARITAL STATUS, HANDICAP (IF OTHERWISE QUALIFIED), AGAINST VETERANS OF THE VIETNAM ERA OR AGAINST VETERANS WITH DISABILITIES.		  


Northern Hills Training Center  : :  625 Harvard Street  : :  Spearfish, SD 57783  : :  Telephone: 605-642-2785  : :  click here to email us
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