Who We Are

Employment Application

Passion. That’s the common attribute of those that work for our organization.

We are dedicated to helping the people who utilize our services. If you’re ready to make a difference, browse our openings or upload your resume and tell us your interests. We’ll consider you for future opportunities.

An Equal Opportunity Employer

Pembina County Memorial Hospital Association is an Equal Opportunity Employer. Pembina County Memorial Hospital Association does not discriminate on the basis of race, religion, color, sex, age, national origin, or disability, or on any basis prohibited by local, state, or federal law.  Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.

PLEASE READ BEFORE CLICKING APPLY:  Please fill out all of the fields below and upload resume before clicking apply.  

Employment Application

Applicant Information
Name of Applicant:
First Name
Last Name
Suffix
Phone Number:
Country
Address Line 1
City
State
Postal Code
How were you referred to us?
Employment Positions
Position(s) applying for:

Are you applying for:

Temorary work- such as summer or holiday work?
Regular part-time work?
Regular full-time work?
What days and hours are you available for work?
If applying for temporary work, when will you be available?
If hired, on what date can you start working?
Can you work on the weekends?
Can you work on the weekends?
Can you work evenings?
Can you work evenings?
Are you available to work overtime?
Are you available to work overtime?
Starting salary you are seeking?
($____________ per_____________)
Personal Information
If hired, would you have transportation to/from work?
If hired, would you have transportation to/from work?
Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.)
Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.)
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?
If hired, would you be able to present evidence of your U.S. citizenship or proof of your legal right to work in the United States?
If hired, are you willing to submit to and pass a controlled substance test?
If hired, are you willing to submit to and pass a controlled substance test?
Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?
Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation?
If no, describe the functions that cannot be performed:

(Note: Pembina County Memorial Hospital Association complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)

PLACEMENT
Education, Training and Experience
High School (Name and Address of School)
Last Year Completed
Did you Graduate?
Did you Graduate?
Major Course of Study and Degrees Granted
College (Name and Address of School)
Did you Graduate?
Did you Graduate?
Last Year Completed
Major Course of Study and Degree Granted
Vocational School ( Name and Address of School)
Last Year Completed
Did You Graduate?
Did You Graduate?
Major Course of Study and Degree Granted
Branch:
Rank:
Total years of service:
Skills/Duties:
Related details:
Additional Infromation
Do you speak, write or understand any foreign languages?
Do you speak, write or understand any foreign languages?
If yes, list languages(s) and how fluent of a speaker you consider yourself to be
Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us?
Do you have any other experience, training, qualifications, or skills which you feel should be brought to our attention, in the case that they make you especially suited for working with us?
If yes, please explain:
EMPLOYMENT HISTORY
Are you currently employed?
Are you currently employed?
May we contact you at your current employer?
May we contact you at your current employer?

Below, please describe past and present employment positions, dating back five (5) years. Please account for all periods of unemployment. Even if you have attached a resume, this section must be completed.

1. Present or last Employer
Business Type
Name and Title of Supervisor
Address
Country
Address Line 1
City
State
Postal Code
Phone Number
Dates
Positions Held
Reason for Leaving
May we contact this employer for references?
May we contact this employer for references?

_____________________________________________________________________________

2. Present or last Employer
Business Type
Name and Title of Supervisor
Address
Country
Address Line 1
City
State
Postal Code
Phone Number
Dates
Positions Held
Reason for Leaving
May we contact this employer for references?
May we contact this employer for references?

_____________________________________________________________________________

3. Present or last Employer
Business Type
Name and Title of Supervisor
Address
Country
Address Line 1
City
State
Postal Code
Phone Number
Dates
Positions Held
Reason for Leaving
May we contact this employer for references?
May we contact this employer for references?
If there has been a gap in employment of more than six (6) months, please provide details below.
(Attach sheet if more space is needed)
REFERENCES
References ( Name, Address, Telephone, Occupation, and Number of years acquainted)
Please read and initial each paragraph, then sign below.
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure employment can be grounds for rejection of application or, if I am employed by Pembina County Memorial Hospital Association, terms for my immediate expulsion from Pembina County Memorial Hospital Association.
I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or on any document used to secure employment can be grounds for rejection of application or, if I am employed by Pembina County Memorial Hospital Association, terms for my immediate expulsion from Pembina County Memorial Hospital Association.
I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or Pembina County Memorial Hospital Association.
I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, and by either me or Pembina County Memorial Hospital Association.
I permit Pembina County Memorial Hospital Association to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release Pembina County Memorial Hospital Association, my former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.
I permit Pembina County Memorial Hospital Association to examine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release Pembina County Memorial Hospital Association, my former employers, and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.
Please type your full name for a Signature:
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