Job Opportunities

EMPLOYMENT INQUIRY

I understand this is only a form sent to let Pembina County Memorial Hospital know that I am interested in a position and that this is not a guarantee that I will be hired or employed.

Personal Information

First Name

Last Name

Middle Initial

Street Address

Address (cont.)

City

State

Zip Code

Home Phone

E-mail

Position Applied For

Name of High School or GED

HS Diploma or GED? Yes No

Name of College or Technical School

Years Completed
Degree Obtained: Yes No

Professional Licenses, Registration and/or Certifications

Type

State issued

Date issued

Expires

Number

Eligible

Employment Information
Start with your current or most recent job.

#1
Dates of employment: StartEnd
Supervisor
Telephone #
Position
Ending Salary
Briefly describe work performed

Reason for leaving
May we contact this employer Yes No

#2
Dates of employment: StartEnd
Supervisor
Telephone #
Position
Ending Salary
Briefly describe work performed

Reason for leaving
May we contact this employer Yes No

#3
Dates of employment: StartEnd
Supervisor
Telephone #
Position
Ending Salary
Briefly describe work performed

Reason for leaving
May we contact this employer Yes No

#4
Dates of employment: StartEnd
Supervisor
Telephone #
Position
Ending Salary
Briefly describe work performed

Reason for leaving
May we contact this employer Yes No

Additional Comments

By clicking on the "Send Application" button below, I certify that all of the information in this application is true and correct to the best of my knowledge. If this information is found to be untrue or incorrect, PCMH reserves the right to deny and destroy the application.
This will take a few moments to send, please click the "Submit Application" button only once.