NDHC Job Application | Northwood Deaconess Health Center

Job Application

Position you are applying for

Available Start Date

Highest education earned

If other

If other, please specify

Professional Licenses

Please list professional licenses.

State Issued

License Number

Other Certification

Expires

Other Certification

Expires

Employment History

Current / Most recent employer

Job title

Supervisor Name

Supervisor Phone

Supervisor Email

May we contact this employer?

Yes

Reason for leaving?

Describe duties performed, skills used/learned, advancements, promotions, recognitions received.

Employer 2

Past Employer

Job Title

Supervisor Name

Supervisor Phone

Supervisor Email

May we contact this employer?

Yes

Reason for leaving?

Describe duties performed, skills used/learned, advancements, promotions, recognitions received.

Employer 3

Past Employer

Job Title

Supervisor Name

Supervisor Phone

Supervisor Email

May we contact this employer?

Yes

Reason for leaving?

Describe duties performed, skills used/learned, advancements, promotions, recognitions received.

References

Reference 1

Name

Relationship

Phone Number

Reference 2

Name

Relationship

Phone Number

Reference 3

Name

Relationship

Phone Number

Waivers

Please read carefully

I authorize NDHC to contact any or all references listed to obtain previous employment or other pertinent information, including but not limited to contacting anyone deemed appropriate to investigate or verify any information I have provided and to discuss suitability for employment, background, past performance, education or related matters.

Yes

I release the above-mentioned references and/or supervisors from any and all liability from any damages that may result from information collected by NDHC. I expressly consent to NDHC contacting references and/or supervisors and consent to resulting discussions. I voluntarily and knowingly waive all rights to bring any action for defamation, invasion of privacy, or similar cause of action against anyone providing or requesting such information.

Yes

I understand that verification of eligibility to work in the United States, in addition to background checks, may be completed by NDHC from a third party consumer reporting agency for employment purposes. You may be the subject of a “consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (driving record), verification of your education or employment history, or other background checks. You 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. The scope of this disclosure is all-encompassing, however, allowing NDHC to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law.

Yes

Have you ever been convicted of a felony?

Yes

If yes, please provide additional information to include the number of conviction(s), nature of offenses(s), when committed, sentence(s) imposed, types of rehabilitation.

I understand NDHC and its employees have an employment at-will relationship. Either NDHC or an employee may terminate the employment relationship at any time for any reason not prohibited by state and federal law.

Yes

I certify the information provided in this application is true and complete to the best of my knowledge. I understand that any falsification, whether intentional or accidental, is grounds for disqualification of employment consideration.

Yes

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EMPLOYMENT APPLICATION

Job Application

Professional Licenses

Employment History

References

Waivers

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