NDUTIME Employment Application

Position/Title:

Position #:

Personal Information:

Salutation:

First Name:

Last Name:

Address:

City:

State:

Zipcode:

Business Phone#:

Home Phone #:

Cell Phone #:

Email Address:

May correspond with you via email?:

Are you legally eligible for employment in the U.S.?:

Are you a current NDUTIME employee or have you worked for NDUTIME in the past?:

If yes, when?:

What department?:

Your name when employed by the NDUTIME (if applicable)?

Please list any relatives currently employed by NDUTIME:

Do you have a valid drivers license?

Commercial driver’s license?:

License ID Number:

Issuing State:

Expiration Date:

List CDL Endorsements (if any):

Have you ever been convicted of a: Felony?

Misdemeanor? Any traffic infraction (moving violation)?

If yes, please explain and give dates:

(A conviction does not automatically eliminate you from employment consideration. The nature of the offense, when it occurred, and your truthfulness may be taken into
consideration.)

Have you ever been fired or asked to resign from a job?

If yes, give date(s), name and address of employer, and reason:
(A firing or forced resignation does not automatically eliminate you from employment consideration. The circumstances, time elapsed, and employment record may be
considered. However, failure to be completely truthful and accurate about such circumstances may cause you to be disqualified from employment consideration.)

EDUCATION HISTORY

Name and Address:	Type of School:	From/To (Mo/Yr)	Years Completed:	Major / Degree (if applicable):	Did you graduate?

WORK HISTORY

Give a complete record of your employment history including part-time work military service, and volunteer experience. List all experience in order, starting with your present or most recent position and working back:

Dates of Employment:		Name of Employing firm:	Immediate Supervisor:
From:	To:
		Mailing Address (including zipcode)	Name:
Type of Position:			Title:
		Phone:	Starting Salary:
If part-time, list hours per week: Reason for leaving:		Job Title:	Final Salary:
		Your name when employed (if different):	Pay Basis:
			Number and the title of people you supervised:

Description of duties:

Equipment used (if listing personal computer, include software in which you are proficient)

Dates of Employment:		Name of Employing firm:	Immediate Supervisor:
From:	To:
		Mailing Address (including zipcode)	Name:
Type of Position:			Title:
		Phone:	Starting Salary:
If part-time, list hours per week: Reason for leaving:		Job Title:	Final Salary:
		Your name when employed (if different):	Pay Basis:
			Number and the title of people you supervised:

Description of duties:

Equipment used (if listing personal computer, include software in which you are proficient)

Dates of Employment:		Name of Employing firm:	Immediate Supervisor:
From:	To:
		Mailing Address (including zipcode)	Name:
Type of Position:			Title:
		Phone:	Starting Salary:
If part-time, list hours per week: Reason for leaving:		Job Title:	Final Salary:
		Your name when employed (if different):	Pay Basis:
			Number and the title of people you supervised:

Description of duties:

Equipment used (if listing personal computer, include software in which you are proficient)

SKILLS INVENTORY

Current # of words per minute:

Typing:

Standard:

May we contact your former employers?:

Present Employer:

If no, when?:

Use this space for any special qualifications you may have relevant to the position for which you are applying:

Please list your professional memberships:

Please list your professional certificates, designations, licenses, honors, awards, fellowships, etc.

The statements made by me in this application are true and complete to the best of my knowledge. I understand that any willful misstatements or
material omissions in this application will be sufficient cause to disqualify me from employment consideration with NDUTIME Youth & Family Services, Inc. If such misstatements or omissions are found after employment, it will be considered grounds for dismissal.

I understand that this completed application and any materials submitted with it are the property of NDUTIME Youth & Family Services, Inc. and will not be returned. In the case of a panel interview, which may consist of non-NDUTIME employees, I authorize my application to be viewed by members of the panel.

I also understand that any offer of employment is contingent upon my ability to produce documentation as required by the Immigration and Naturalization Service documenting eligibility for employment. Further, some positions may require drug/alcohol testing before and/or after employment.

I authorize the release of any and all job-related information that NDUTIME Youth & Family Services, Inc. may request or any records pertaining to past or present employment which may now exist or in the future exist.

BY SIGNING BELOW, I certify that I have read and agree with these statements.