Fillable APPLICATION FOR EMPLOYMENT

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APPLICATION FOR EMPLOYMENT

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The APPLICATION FOR EMPLOYMENT form is 5 pages long and contains:

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  • 15 check-boxes
  • 182 other fields

Country of origin: OTHERS
File type: PDF

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CURRENT EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
APPLICATION FOR EMPLOYMENT
FILL OUT COMPLETELY USING INK – PLEASE PRINT
(Please let us know if you need assistance in completing this application.)
EMPLOYMENT EXPERIENCE – Please do not substitute "see resume" in place of completing this application.
START WITH YOUR CURRENT OR YOUR MOST RECENT JOB. COMPLETE JOB HISTORY FOR AT LEAST THE LAST THREE EMPLOYERS.
INCLUDE MILITARY DUTY AND VOLUNTEER ACTIVITIES. ACCOUNT FOR ALL GAPS IN EMPLOYMENT.
You may exclude experiences which
reveal age, ancestry, disability, national origin, race, religion, gender, sexual orientation, gender identity, or other protected status.
The Company is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual
orientation, gender identity, national origin, disability, or protected Veteran status. The Company provides reasonable accommodations to qualified individuals with disabilities, in accordance
with the Americans with Disabilities Act and applicable federal, state, and local laws. If you are an individual with a qualified disability as defined by state, federal, or local law, and require a
reasonable accommodation to complete any part of this application for any position, please contact Human Resources at 701-530-1357 or your state employment agency for assistance.
AN EQUAL OPPORTUNITY EMPLOYER
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
An MDU Resources Company
POSITION APPLIED FOR:
DATE:
TELEPHONE NUMBER: 2
nd
TELEPHONE NUMBER:
( ) ( )
LAST NAME: FIRST NAME: MIDDLE NAME:
ADDRESS: CITY: STATE: ZIP CODE:
E-MAIL ADDRESS:
PLEASE CONTINUE – OVER
20062-CSG(7-04) (Rev. 9/17) Oregon
HIGH SCHOOL/EQUIVALENCY
DIPLOMA
COLLEGE/UNIVERSITY:
TRADE/TECHNICAL
OTHER:
EDUCATION / TRAINING
TYPE OF SCHOOL
NAME & LOCATION OF
SCHOOL
COURSE OF STUDY
NO. YEARS
COMPLETED
DID YOU GRADUATE?
Diploma / Degree / Major
N/A
SUPPLEMENT EMPLOYER PAGE
CURRENT EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
EMPLOYMENT EXPERIENCE (Cont.)
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
PREVIOUS EMPLOYER:
ADDRESS:
JOB TITLE: SUPERVISOR:
WORK PERFORMED:
DATES EMPLOYED
FROM: TO:
PHONE:
REASON FOR LEAVING:
OTHER COMMENTS/INFORMATION:
MAY WE CONTACT YOUR CURRENT EMPLOYER: HAVE YOU BEEN EMPLOYED BY US IN THE PAST? q Yes q No
q Yes q No If Yes, Provide Dates & Location:
PROOF OF ELIGIBILITY TO WORK
I ACKNOWLEDGE THAT EMPLOYMENT IS CONTINGENT UPON BEING ABLE TO PROVE MY ABILITY TO LEGALLY WORK IN
THE UNITED STATES.
APPLICANT’S STATEMENT
THE INFORMATION PROVIDED IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT A MISREPRESENTATION OR
OMISSION BY ME ON THIS APPLICATION OR DURING THE INTERVIEW PROCESS WILL BE CAUSE FOR CANCELLATION OF THE APPLICATION
OR DISMISSAL, IF EMPLOYED.
I AUTHORIZE THE COMPANY TO VERIFY THE INFORMATION CONTAINED IN THIS APPLICATION. I FURTHER AUTHORIZE AND REQUEST
THAT ALL OF MY PRESENT AND FORMER EMPLOYERS AND THOSE INDIVIDUALS I HAVE LISTED AS REFERENCES FURNISH INFORMATION
ABOUT MY EMPLOYMENT RECORD, INCLUDING A STATEMENT OF THE REASON FOR THE TERMINATION OF MY EMPLOYMENT, WORK
PERFORMANCE, ABILITIES, AND OTHER QUALITIES PERTINENT TO MY QUALIFICATIONS FOR EMPLOYMENT, HEREBY RELEASING THEM
FROM ANY AND ALL LIABILITY FOR DAMAGES ARISING FROM FURNISHING THE REQUESTED INFORMATION.
I ALSO UNDERSTAND THAT I WILL BE REQUIRED TO ABIDE BY ALL RULES AND REGULATIONS OF THE EMPLOYER AS THEY NOW EXIST
AND AS THEY ARE AMENDED FROM TIME TO TIME AT THE COMPANY’S SOLE OPTION. ANY OFFER I RECEIVE FROM THE COMPANY IS
CONTINGENT UPON MY SUCCESSFUL COMPLETION OF THE COMPANY’S TOTAL PRE-EMPLOYMENT SCREENING PROCESS. I ACKNOWLEDGE
THAT FOR CERTAIN JOBS I MAY BE REQUIRED TO SUBMIT TO PRE-EMPLOYMENT DRUG TESTING AND/OR TO TAKE A PHYSICAL. COMPLIANCE
IS A REQUISITE FOR EMPLOYMENT.
I UNDERSTAND THAT I WILL NOT HAVE A CONTRACT OF EMPLOYMENT BETWEEN MYSELF AND THE COMPANY FOR ANY SPECIFIED PERIOD
OF TIME. I ALSO UNDERSTAND THAT SUBJECT TO APPLICABLE LAW, THE EMPLOYMENT RELATIONSHIP IS AN "AT-WILL" RELATIONSHIP.
AS SUCH, IT MAY BE TERMINATED BY MYSELF, OR BY THE COMPANY, AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT NOTICE. THIS
APPLICATION IS NOT AN OFFER OF EMPLOYMENT.
I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS.
_____________________________________________________________ ________________________________________________
SIGNATURE OF APPLICANT DATE
PROFESSIONAL REFERENCES
(MANAGERS, SUPERVISORS, COLLEAGUES WHO CAN ATTEST TO YOUR KNOWLEDGE, ABILITIES, CHARACTER, AND PERSONALITY)
NAME ADDRESS RELATIONSHIP TELEPHONE NO.
1
2
3
THESE QUESTIONS ARE ASKED IN ORDER FOR THE COMPANY TO COMPLY WITH THE FEDERAL REGULATIONS REGARDING EMPLOYMENT
OF PERSONS ASSOCIATED WITH IT'S INDEPENDENT AUDITORS (17 C.F.R. § 210.2-01) AND WILL BE USED ONLY FOR THAT PURPOSE.
Have you ever been employed by Deloitte & Touche LLP? q Yes q No
If yes, do you have a continuing financial interest in Deloitte & Touche LLP? q Yes q No
Do you have a spouse, spousal equivalent, parent, child, brother, or sister who works for the accounting firm of Deloitte & Touche LLP?
q Yes q No
If the answer to the preceding question is yes, please answer the following questions:
• What does this family member do for Deloitte & Touche LLP? ___________________________________________________________________
• Is this family member employed at the Minneapolis, Minnesota office of Deloitte & Touche LLP? q Yes q No
• Does this family member do any work for Deloitte & Touche LLP that involves MDU Resources Group, Inc. or any of its affiliates? q Yes q No
Clear Form
ADDITIONAL INFORMATION – VOLUNTARY SELF-IDENTIFICATION FORM FOR APPLICANTS
The Company is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order
to comply with these laws, the employer invites applicants to voluntarily self-identify their race or ethnicity along with protected Veteran status. Submission
of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and
may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be
summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.
Name: __________________________________________________________ Telephone No.: __________________________ Gender: ____________
(Last / First / Middle)
Address: _________________________________________________________________________________________________________________
(Address / City / State / Zip)
ETHNIC BACKGROUND: (Check One)
q
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
q
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
q
Black or African American (Not Hispanic or Latino) -
A person having origins in any of the black racial groups of Africa.
q Native Hawaiian or Other Pacific Islanders (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other
Pacific Islands
q
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent,
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
q
American Indian or Alaskan Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America
(Including Central America), and who maintain tribal affiliation or community attachment.
q
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 as amended by the Jobs for Veterans Act
of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment:
• Disabled Veteran: A Veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired
pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs OR a person who was discharged or released from
active duty because of a service-connected disability.
• Recently separated Veteran: Any Veteran during the three-year period beginning on the date of such Veteran’s discharge or release of active duty in the
U.S. military, ground, naval, or air service.
• Active duty wartime or campaign badge Veteran: a Veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or
in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
• Armed Forces service medal Veteran: a Veteran who, while serving on active duty in the U.S. military, ground naval or air service, participated in a United
States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Veteran Status: If you believe you belong to any of the categories of protected Veterans listed above, please indicate by checking the appropriate box below.
As a government contractor subject to VEVRAA, we request this information to measure the effectiveness or the outreach and positive recruitment efforts
we undertake pursuant to VEVRAA.
q I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE
q I AM NOT A PROTECTED VETERAN
Protected Veterans may have additional rights under USERRA–the Uniformed Services Employment and Reemployment Rights Act. In particular, if you
were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position
you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans
Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.
HOW WERE YOU REFERRED TO US:
q
Newspaper Ad q Private Placement Firm q State Employment/Workforce Agency
q
School Placement Office q Company Web Site/jobs.mdu.com q Employee Referral________________________________
OTHER: q Name of Referral Source: ____________________________________ q Veteran Referral Source: ________________________________
q Disabled Individual Referral Source: ___________________________ q Female Referral Source: ________________________________
q Minority Referral Source: ____________________________________
Date of Application: ___________________________________ Job Applying For: _______________________________________________________
Signature of Applicant: (q Applicant digitally signed this document): ___________________________________________________________________
An Equal Opportunity Employer/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race,
color, religion, gender, sexual orientation, gender identity, national origin, disability, or protected Veteran status.
– Confidential Information - Return to Human Resources Dept. –
q Female
q Male
20565(7-04)
(Rev. 3/15)
Clear Form
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☐
Voluntary Self-Identification of Disability
Form CC-305
Page 1 of 1
OMB Control Number 1250-0005
Expires 05/31/2023
Name: Date:
Employee ID:
(if applicable)
Why are you being asked to complete this form?
We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people
with disabilities. We are also required to measure our progress toward having at least 7% of our workforce be individuals
with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability.
Because a person may become disabled at any time, we ask all of our employees to update their information at least
every five years.
Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer
will be maintained confidentially and not be seen by selecting officials or anyone else involved in making personnel
decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in
the past. For more information about this form or the equal employment obligations of federal contractors under Section
503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs
(OFCCP) website at www.dol.gov/ofccp
.
How do you know if you have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially
limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities
include, but are not limited to:
• Autism
•
Autoimmune disorder, for example,
lupus, fibromyalgia, rheumatoi
d
a
rthritis, or HIV/AIDS
•
Blind or low vision
•
Cancer
•
Cardiovascular or heart disease
•
Celiac disease
•
Cerebral palsy
•
Deaf or hard of hearing
•
Depression or anxiety
•
Diabetes
•
Epilepsy
•
Gastrointestinal disorders, for
example, Crohn's Disease, or
irritable bowel syndrome
•
Intellectual disability
•
Missing limbs or partially missing
limbs
•
Nervous system condition for
example, migraine headaches,
Parkinson’s disease, or Multiple
scl
erosis (MS)
•
Psychiatric condition, for example,
bipolar disorder, schizophrenia,
PTSD, or major depression
Please check one of the boxes below:
Yes, I Have A Disability, Or Have A History/Record Of Having A Disability
No, I Don’t Have A Disability, Or A History/Record Of Having A Disability
☐
I Don’t Wish To Answer
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond
to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5
minutes to complete.
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APPLICATION FOR EMPLOYMENT

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Completed 10 March 2021

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