Position Applying For* Date* Last Name* First Name* Middle Initial* Telephone* Email* PERSONAL INFORMATION Street Address* City* State* Zip* Have you ever served in the military?* YESNO If yes, what branch? Date of service Date of discharge Honorable discharge? YESNO Attach copy of DD214 OTHER EMPLOYMENT RELATED INFORMATION Check the following options which you would consider* FULL-TIMEPART-TIME Do you claim Indian preference?* YESNO If yes, identify Tribe and attach verification Attachment Are you eligible to work in the United States?* YESNO Were you previously employed by any companies owned and/or operated by the Flandreau Santee Sioux Tribe?* YESNO If yes, where: Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?* YESNO Have you ever been convicted of a Felony, pled No Contest in a Felony, been convicted of a Misdemeanor resulting in Imprisonment, fined over $500.00, or been convicted of a Violent Crime involving a Child, Sexual Assault, Molestation, Exploitation, Contact or Prostitution, in the last ten years?* YESNO If yes, explain all offenses: EDUCATION AND TRAINING High School* Address* Complete?* YESNO College or University Address Degree Major Degree Year Complete? YESNO College or University Address Degree Major Degree Year Complete? YESNO Trade/Apprentice School Address Degree Subjects Completion Year Complete? YESNO List any other Education, Training, Special Skills, Certificates and Licenses that you possess related to this job* List any Machines or Equipment that you are qualified to operate List any Languages you can speak List any Languages you can read List any Languages you can write UPON OFFER OF EMPLOYMENT YOU WILL BE REQUIRED TO SUBMIT TO A BACKGROUND CHECK & A DRUG AND ALCOHOL SCREENING. REFUSAL TO SUBMIT TO OR FAILURE TO PASS SUCH REQUIREMENTS WILL RESULT IN IMMEDIATE TERMINATION OF EMPLOYMENT OR JOB OFFER. EMPLOYMENT HISTORY List your last ten years work experience, beginning with the most recent. This must be completed regardless of Resume/CV submittal: Employer 1 Name of Employer* Type of Business* Address* City* State* Zip* Phone* Employment Dates* Starting Title* Last Title* Name of Supervisor* Current or Ending Wage:* Was employed* FULL-TIMEPART-TIME May we contact?* YESNO Reason for leaving* Brief Description of Duties* Employer 2 Name of Employer Type of Business Address City State Zip Phone Employment Dates Starting Title Last Title Name of Supervisor Ending Wage: Was employed FULL-TIMEPART-TIME May we contact? YESNO Reason for leaving Brief Description of Duties Employer 3 Name of Employer Type of Business Address City State Zip Phone Employment Dates Starting Title Last Title Name of Supervisor Ending Wage: Was employed FULL-TIMEPART-TIME May we contact? YESNO Reason for leaving Brief Description of Duties Do you have a valid South Dakota Driver's License?* YESNO If yes, State and License Number Are you insurable?* YESNO List any moving violations during the last five years, if any List any comments or qualifying statements you make care to make Please read carefully before signing. If you have any questions regarding the following statements, please ask for assistance. I certify that to the best of my knowledge and belief, the answers given by me in this application are correct and complete. I understand that any false information contained in this application may result in my discharge. I authorize you to communicate with any former employers, school officials and persons named as references. I hereby release employers, schools and individuals from any damage whatsoever resulting from giving such information. I understand that as this organization deems necessary, I may be required to work overtime hours or hours outside a normally defined work week. If employed, I agree that such employment may be terminated at any time and without liability to me for any continuation of salary, wages or employment related benefits.* I have read and agree: Date* Full Name* Would you like to apply for any of our other open positions? Police OfficerGrant WriterHousekeepingPatient Registration Manager [recaptcha]
