Employment Information
Do you have a valid driver's license (if req'd)?
No
Yes
License State
Alabama, USA
Alaska, USA
Alberta, Canada
Arizona, USA
Arkansas, USA
British Columbia, Canada
California, USA
Colorado, USA
Connecticut, USA
Delaware, USA
District of Columbia, USA
Florida, USA
Georgia, USA
Hawaii, USA
Idaho, USA
Illinois, USA
Indiana, USA
Iowa, USA
Kansas, USA
Kentucky, USA
Louisiana, USA
Maine, USA
Manitoba, Canada
Maryland, USA
Massachusetts, USA
Michigan, USA
Minnesota, USA
Mississippi, USA
Missouri, USA
Montana, USA
Nebraska, USA
Nevada, USA
New Brunswick, Canada
New Hampshire, USA
New Jersey, USA
New Mexico, USA
New York, USA
Newfoundland, Canada
North Carolina, USA
North Dakota, USA
Northwest Territories, Canada
Nova Scotia, Canada
Ohio, USA
Oklahoma, USA
Ontario, Canada
Oregon, USA
Pennsylvania, USA
Prince Edward Island, Canada
Puerto Rico, USA
Quebec, Canada
Rhode Island, USA
Saskatchewan, Canada
South Carolina, USA
South Dakota, USA
Tennessee, USA
Texas, USA
Utah, USA
Vermont, USA
Virginia, USA
Washington, USA
West Virginia, USA
Wisconsin, USA
Wyoming, USA
Yukon Territory, Canada
State License #
Please list endorsements
Are you eligible to work in the United States?
No
Yes
Please select the location you are applying to.
Fargo
Bismarck
Minot
Jamestown
Bemidji
This application is for the position of: *
Applying for:
Full-Time
Part-Time
Temporary
Per Diem (scheduled as necessary)
Indicate the hours, days & shifts you CANNOT work.
If req'd by this position, are you available to be on-call?
No
Yes
Date available to work
Where did you learn of the job?
Website
Newspaper
Job Service
Other
State briefly why you would like to work for MeritCare HealthCare Accessories
Are you 18 years of age or older (Disclosure of information will not bar consideration for employment. This information is used only to ensure MeritCare HealthCare Accessories complies with state and federal child labor laws)?
No
Yes
Have you ever been convicted of a crime, excluding minor traffic offenses?
No
Yes
If you answered "Yes" in regards to criminal conviction please explain the nature of the offense, when, where and disposition): (Disclosure of information will not bar consideration for employment and will only be considered in relation to specific job requirements.)
Did you graduate from high school or have a GED?
No
Yes
Please list your college, university, professional, trade or other background as well as city and state and whether or not you graduated.
Registration/Certification Type
Registration/Certification #
Registration/Certification State
Registration/Certification Exp. Date (if req'd)
Have you ever had a professional license denied, revoked, suspended, surrendered, placed on probation or been the subject of any restriction, a censure, reprimand or other disciplinary action on any jurisdiction?
No
Yes
If you answered "Yes" in regards to having been discharged or resigning please give name of organization and reason
Please indicate your skills or qualifications relevant to the position you are applying for (computer skills, medical terminology, insurance knowledge, foreign language(s), trade skills, etc.)
Please indicate other educational experience that you feel would help us in determining your qualifications
Have you ever been discharged or forced to resign from any position?
No
Yes
Please read each paragraph below. If there is any part you do not understand, please ask for clarification before submitting.
I hereby authorize MeritCare HealthCare Accessories to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and, further, authorize my current and former employer to disclose to MeritCare HealthCare Accessories any information pertaining to my employment with them, without giving me prior notice of such disclosure.
I understand that if offered employment, the offer may be contingent on my passing an employment drug screen and physical. I understand that failure to pass the drug screen and/or physical will result in withdrawal of the employment offer.
If hired, I also agree that MeritCare HealthCare Accessories may conduct alcohol or drug screening at its sole discretion with or without notice. I also understand that refusal to submit to an alcohol/drug screen will be considered a voluntary resignation of employment.
I understand that nothing contained in the application or conveyed to me during any interview that may be granted is intended to create an employment contract, implied or explicit, between MeritCare HealthCare Accessories and me. I understand that if employed, my employment is voluntary and for no definite period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or MeritCare HealthCare Accessories, and that no promises or representations contrary to the foregoing are binding on MeritCare HealthCare Accessories unless made in writing and signed jointly by the Executive Director and myself.
I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or MeritCare HealthCare Accessories benefits, policies and procedures will not alter our at-will agreement.
I understand that if offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment.
If the position applied for requires driving in the course of work, I understand that I will be required to possess a current and valid driver's license and understand that I will be required to provide a copy of my proof of vehicle insurance. I also understand that any offer of employment is contingent on my ability to be covered by MeritCare HealthCare Accessories auto insurance, if required for my position.
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or on any documents used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
By checking I certify that I have read, understand and agree to the terms and conditions outlined in this document. (mandatory)
I Agree
Select One
No
Yes
