Other
Occasionally the form of an application blank makes it difficult for an individual to adequately summarize his/her complete background. If you wish, use the space below, or attach a separate sheet, to summarize any additional information necessary to describe your full qualifications.
Certification and Agreement
I hereby certify that this application contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any such misrepresentation or falsification, my application will be rejected and I may be removed from the job after appointment. I understand that under Title VII of the Civil Rights Act of 1964 and the North Dakota Human Rights Act, I cannot be discriminated against in employment, including consideration for promotion, for reasons of race, color, religion, national origin, sex, or on the basis of age, physical or mental disability. I further understand that this employment application and other employment related documents I may have been furnished are not contracts of employment; also, that any oral or written statements to the contrary are hereby expressly disavowed. The employer has my authorization to thoroughly investigate my work and personal history which is job-related. I certify that I will hold no person, corporation or organization liable for giving or receiving information in this investigation.
I further understand that if I am employed, such employment is for an indefinite period of time, that either I or the Alliance can terminate such employment at anytime, and that the Alliance can change wages, benefits and conditions at anytime.
Having made application for employment with Northland Healthcare Alliance and desiring them to be informed as to my previous record and character, I hereby authorize Northland Healthcare Alliance to investigate my past record and to ascertain any and all information which may concern my record and character, whether same is of record or not, and release my present and past employers, references, and all persons whomsoever from any damage because of furnishing said information.
Should you receive an offer of employment with Northland Healthcare Alliance, and accept such offer, prior to your employment date, a physical examination by a Medical Center (at no charge to you) may be completed, or if you wish, you may choose a physician at your own cost. Your employment is contingent upon satisfactorily passing a physical examination prior to employment. In addition, Alliance policy provides for an orientation period to allow Northland Healthcare Alliance to review you and your adjustment to the new position. During this orientation period, you or your supervisors have the freedom of terminating employment at Northland Healthcare Alliance without notice.
Thank you for completing this application form and for your interest in employment with Northland Healthcare Alliance. We assure you that your opportunity for employment will be based only on your merit, employment history, and academic background.
Background Check Disclosure & Authorization
Disclosure to Applicant That a Consumer Report May Be Obtained by Employer
Please note that in connection to our application for employment with Northland Healthcare Alliance, we may obtain a “consumer report” as defined in the Fair Credit Reporting Act (FCRA), from a consumer reporting agency. Consumer reports include, but are not limited to, credit reports, criminal background checks and motor vehicle reports.
Authorization for Employer to Obtain Consumer Report
By signing below, I hereby acknowledge that I have read the above disclosure and voluntarily authorize Northland Healthcare Alliance including its agents and representatives, to obtain a consumer report on me for the use in connection with my application for employment with Northland Healthcare Alliance. If hired, I understand that this authorization will remain on file and will serve as an ongoing authorization to the extent permitted by law, for a consumer report to be lawfully obtained at any time in connection with my employment.
The following information is necessary to confirm your identity for completing an accurate background check. It is confidential and will not be taken into consideration in any employment decisions.
Please list previous addresses for the past seven years (In chronological order):
