Employment Application

Personal Information

Job ID:
Name:
E-mail:
Street adress:
City, state, zip:
Phone:
Social Security:
Position desired:
Pay expected:

Ever applied before with us:
If yes, when and where?:

Can you work fulltime?
If no, what hours?

Can you work overtime?
If no, explain why not:

Are you legally eligible to work in the US?:

When will you be available to start work:

Do you have a valid driver's license?
If yes, what state:
If no, explain:

Do you have a motor vehicle insurance?

Have you had any motor vehicle violations within the past 7 (seven) years?
If yes, describe in full

Do you have ever been bonded?
If yes, with what employers:

Have you ever been convicted of any crime (felony or misdemeanor) or a vehicle violation such as DWI in the past 12 (twelve) years?
If yes, describe in full

Do you have a conviction or prior employment history of abuse, neglect or mistreatment?
If yes, describe in full

List names of relatives and friends working for us

Write a short narrative explaining the skills and qualities which you have that will enable you to be a valuable employee:

Other special training/skills:

Membership in civic or professional organizations:
(Exclude those which may disclose your race, color, creed, sex, sexual orientation, age, ethnic or national origin, marital status, disability or veteran status)

Education Information

Elementary School:
Name and location: Years completed
Course of study: Degree / Diploma:

High School:
Name and location: Years completed
Course of study: Degree / Diploma:

Tecnical / Trade School:
Name and location: Years completed
Course of study: Degree / Diploma:

College:
Name and location: Years completed
Course of study: Degree / Diploma:

Graduate:
Name and location: Years completed
Course of study: Degree / Diploma:

Other (online, etc.):
Name and location: Years completed
Course of study: Degree / Diploma:

Employment History

(Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer.)

Company name:Phone:
Adress:City, state, zip:
Employed From - To:Pay Start - Last:
Name of suprvisor:
State job title and job description:Reason for leaving:

Company name:Phone:
Adress:City, state, zip:
Employed From - To:Pay Start - Last:
Name of suprvisor:
State job title and job description:Reason for leaving:

Company name:Phone:
Adress:City, state, zip:
Employed From - To:Pay Start - Last:
Name of suprvisor:
State job title and job description:Reason for leaving:

Company name:Phone:
Adress:City, state, zip:
Employed From - To:Pay Start - Last:
Name of suprvisor:
State job title and job description:Reason for leaving:

References

(list two (2) professional and one (1) personal reference we may contact)

Name:Title:
Adress:Phone:

Name:Title:
Adress:Phone:

Name:Title:
Adress:Phone:
TERMS AND CONDITIONS:
PARTIAL CONDITIONS OF EMPLOYMENT & BACKGROUND INVESTIGATION
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 recieving of any information, requested by NHTC. I release from liability any person giving or recieving 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 fired, may subject me to immediate dismissal. Although the NHTC makes ever 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 it's discretion, and without any prior notice to me. I further acknowledge that my employment may be ended per personal 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 commencements 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, and understand the above.

PROSPECTIVE: EMPLOYEES SHALL RECIEVE CONSIDERATION WITHOUT DISCRIMINATION BECAUSE OF RACE, COLOR, CREED, SEX, SEXUAL ORIENTATION, AGE, ETHNIC OR NATIONAL ORIGIN, MARITAL STATUS, HANDICAP (IF OTHERWISE QUALIFIED), AGAINST VETERANS OF TEH VIETNAM ERA OR AGAINST VETERANS WITH DISABILITIES.

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BACKGROUND INVESTIGATION

Northern Hills Training Center (NHTC) will complete a Criminal Background Investigation on all prospective employees.

NHTC 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.

NHTC may take an offer of employment to a prospective employee contingent upon the results of the Criminal Background Investigation.

NHTC shall withdraw it's 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, assoult, 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.
For questions about this disclaimer, send an e-mail to caldwell@nhtc.org

I agree with the above mentioned terms and conditions

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