EMPLOYMENT APPLICATION

Please note fields with asterik (*) are required for successful submission.

Position you are applying for

Years of related work experience.

If other

Desired employment

Professional Licenses

If required of a position you're applying, please list your active professional licenses(s).

State Issued

Expires

Other(s): Active/Current

Employment History

Current / Most recent employer

Job title

Length of Employment

Past Employer

Job Title

Length of Employment

Briefly describe relevant past work experience, work accomplishments, achievements, and/or credentials.

Waivers*

Please read carefully

I understand that verification of eligibility to work in the United States, in addition to background checks, will be completed by NDHC from a third party consumer reporting agency for employment purposes. I may be the subject of a “consumer report” which may include information about character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding credit history, criminal history, social security verification, motor vehicle records (driving record), verification of education or employment history, reference or other background checks. I have the right, upon written request made within a reasonable time, to request whether a consumer report has been run and to request a copy of your report. These searches will be conducted by Eide Bailly LLP, 4310 17th Ave. S., Fargo, ND 58108, 866-999-8362, www.eidebailly.com.

Acknowledgement

Yes

I certify I am at least 16 years of age and eligible to work in the United States and that information provided in this application is true and complete to the best of my knowledge.

Acknowledgement

Yes