Employment Application Employment App First Name * Last Name * Address * City * State * Zip Code * Home or Cell Phone * Work Phone Email Position(s) Applying for(check all that apply) * Business Office Social Work Dorm Staff Kitchen/Laundry/Housekeeping Farm/Ranch Maintenance Other Employment Condition: (check all that apply) Full Time Part Time Seasonal/Temporary Other Are there times you would not be available to work? * Have you applied to Home On The Range before? * No Yes If yes, when? TO THE APPLICANT: Satisfactory Criminal Background Checks are required for all applicants for employment with HOTR by the North Dakota Department of Human Services. Please respond to the following questions. A “Yes” answer to any question will not necessarily disqualify you from employment. Have you ever been convicted, plead guilty, or “no contest” to a crime (excluding parking or speeding tickets or other minor traffic offenses)? If you answer “Yes” to this question, please describe the offense, date of conviction or plea, any sentence imposed, and state whether you are presently subject to probation or any conditions of sentencing. [Attach additional sheets if necessary.] * No Yes If yes, please explain. Do you presently have pending criminal charges, are you awaiting trial, or sentencing on any criminal charge? * No Yes If you answer “Yes” to this question, please provide additional information on the nature of the pending charges, describe the alleged offense, and provide information on the dates of any pending hearings or legal proceedings. [Attach additional sheets if necessary.] If Yes, please explain: Education List school attended, dates enrolled, major/minor, and degrees earned. Graduate School: College/University: Vocational School: High School: Employment History List current employer first May we contact your present employer? * Yes No Previous Employer Information: Employer Name: Employer Address: Start Date: End Date: Job Title: Hours Per Week: Salary: Specific Duties: Supervisors Name: Supervisor’s Phone: Reason for Leaving: plus1 Add Another Employer minus1 Remove This Employer List any volunteer or unpaid work experiences you have had: Are you willing to do shift work? * Yes No List any special training received: What prompted you to apply at Home On The Range? * Do you have a valid driver’s license? * Yes No If no, explain: Do you know any Home on the Range staff? * Yes No If yes, who? Home On The Range accepts children of all races, creeds and colors and employs staff without regard to the race, color, sex, age, religion, national origin or handicapped status. As a prospective employee, do you have any prejudices that would affect the way your treat the children placed here or the people you could possibly be working with? In case of medical emergency, who should be notified? Emergency Contact Name: Relationship Emergency Contact Address: Emergency Contact City, State, Zip Code Emergency Contact Phone: Please list four people, other than relatives, who will accurately attest to your working abilities. References: Name: Occupation: Address: City, State, Zip Code Phone: plus1 Add Another Reference minus1 Remove This Reference Please Note Smoking is Prohibited on All Home On The Range Property! UNSIGNED OR INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. I hereby certify that all information on this application is true, correct and complete to the best of my knowledge and contains no willful falsifications or misrepresentations. I am aware that falsifications or misrepresentations may disqualify me from consideration from this and future positions of employment or, if hired, may be grounds for termination. Typing your full name in this box will be considered your official signature on this form. Date reCAPTCHA If you are human, leave this field blank. Submit