Fillable Printable Application for Employment - North Dakota
Fillable Printable Application for Employment - North Dakota
Application for Employment - North Dakota
APPLICATION FOR EMPLOYMENT
STATE OF NORTH DAKOTA
SFN 10950 (11-12)
• Follow instructions carefully • Print or type
• Provide detail – do not use “see resume” • Check for errors & signature before submitting
• If accommodation or assistance is needed in completing this application, contact the employing agency.
Position applying for:
Position Number
Requisition Number
General Information
Name (Last, First, Middle Initial)
Work Telephone
Home Telephone
Email Address
Mailing Address
City
State
Zip Code
Have you ever been a student of the North Dakota University System or an employee of the State of North Dakota?
No Yes If yes, please indicate your student or employee ID number, if known, and your former name(s) if your
name changed.
Can you provide proof, if hired, that you are eligible to work in the United States? Yes No
Have you ever been convicted of a crime other than a minor traffic violation? Yes No
If yes, please explain
(Convictions are not an absolute bar to employment but will be considered in relationship to the job requirements.)
How did you learn about this opening?
Veteran's Preference
Veteran Eligibility: You must be a North Dakota resident and have served in the active military forces during a period of
war or received the a rmed forces expeditionary or other campaign service medal during an emergency condition, and
must have been released under other than dishonorable conditions. See North Dakota Century Code 37-19.1.
Do you claim preference as a:
Veteran No Yes – Attach DD-214, Report of Separation
Disabled Veteran No Yes – Attach DD-214 & letter less than 1 yr. old from veterans’ administration indicating
disability
Spouse of Disabled Veteran
No Yes – Attach copy of marriage certificate, DD-214, & letter less than 1 yr. old
from veterans’ administration indicating disability
Spouse of Deceased Veteran
No Yes – Attach copy of marriage certificate, DD-214, & veteran’s death certificate
Education and/or Training
Did you graduate from high school or receive a GED Certificate? Yes No
Number of
Credits
Field
SCHOOL NAME AND LOCATION
(college, business, nursing, vocational, or
other)
Qtr.
Sem.
Major
Minor
Did you graduate?
Diploma or
degree
earned
Yes
No
Yes
No
Yes
No
Computer skills, related volunteer experience, and other education/training/skills:
License or Certification
License/Certification State Profession License/Certification # Expiration Date
Employment History: (Provide detail; do not use “see resume.”)
Start with your current or last job – include armed forces service and self-employment.
Any change of job title under the same employer should be considered a separate position.
Complete pages 3 and 4 if you have additional employment history.
May we contact your current employer for a reference? Yes No Not Applicable
1.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving or Reason for Considering Leaving if Still Employed
2.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving or Reason for Considering Leaving if Still Employed
3.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving or Reason for Considering Leaving if Still Employed
Go on to page 3 if you have additional employment history.
I certify that all information contained in this application and any attachments is true and complete to the best of my knowledge. I
understand that any willful misrepresentation, false statement, or omission by me in the application or interview process will be cause
for rejection of my application or termination of my employment. I authorize investigation of all statements made on this application and
any attachments, and I release all persons, companies, and organizations from liability for providing or receiving such information. I
further understand that this employment application and other employment related documents are not contracts of employment; and,
that any oral or written statements to the contrary are hereby expressly disavowed. A typed name is considered a signature.
Applicant's Signature Date
All information provided is subject to the North Dakota Open Records Law.
As employers, the State of North Dakota and political subdivisions prohibit smoking in all places of state and political subdivision employment in
accordance with N.D.C.C. § 23-12-10.
Equal Opportunity Employer
The State of North Dakota does not discriminate on the basis of race, color, national origin, sex, genetics, religion, age, or disability in
employment or the provision of services and complies with the provisions of the North Dakota Human Rights Act.
SFN 10950 - Page 2
Name:
Additional Employment History:
4.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
5.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
6.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
SFN 10950 - Page 3
Name:
Additional Employment History:
7.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
8.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From:
To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
9.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From:
To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
SFN 10950 - Page 4
Name:
Additional Employment History:
10.
..
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
11.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
12.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
SFN 10950 - Page 5
Name:
Additional Employment History:
13.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
14.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
15.
Employer
Telephone Number
Supervisor's Name
Type of Business
Address
Your Job Title
Dates Employed (indicate months & years)
From: To:
Average Hours Worked Per
Week
Duties:
Monthly Salary
Reason for Leaving
SFN 10950 - Page 6
