Fillable GENERAL INFORMATION (North Dakota State Electrical Board)

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GENERAL INFORMATION (North Dakota State Electrical Board)

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GENERAL INFORMATION
Name (Last, First, Middle Initial)
Telephone Number
Cell Phone Number
Email Address
Mailing Address
City
State
ZIP Code
As of the date of hire, will you be at least 18 years old?
☐ No ☐ Yes
Can you provide proof, if hired, that you are eligible to work in the United States?
☐ No ☐ Yes
Have you ever been convicted of a crime (other than a minor traffic violation)? (Note: Convictions are not an absolute bar to
employment but will be considered in relationship to the job requirements).
☐ No ☐ Yes - Explain
How did you learn about this opening?
VETERAN’S PREFERENCE
• In order to claim veterans’ preference, per North Dakota Century Code 37-19.1 the following conditions must be
satisfied:
o Served on continuous federalized active military duty for at least 180 days or the full period ordered to active
military duty for reasons other than training and,
o Released under other than dishonorable conditions; or
o Honorably discharged from the national guard or a reserve unit located within North Dakota; and
o Has completed a minimum of twenty years of service; or
o Served in a combat zone.
Veteran Status (descriptions below)
☐ None or N/A ☐ Veteran ☐ Disabled Veteran ☐ Spouse of Disabled Veteran
☐ Un-remarried Spouse of Deceased Veteran
• None: Designates a nonveteran or not applicable.
• Veteran: You must satisfy the condition of eligibility as stated above. Candidate must attach a copy of their DD Form 214
showing character of service.
• Disabled Veteran: You must satisfy condition of eligibility as stated above and have a current disability rating with the Federal
VA. Candidate must attach their DD Form 214 or NGB 22 showing character of service, along with a letter less than 1 year old
from Veterans Affairs indicating disability.
• Spouse of Disabled Veteran: Veteran must satisfy conditions of eligibility as stated above and have a 100% service-connected
disability rating from the Federal Department of Veterans Affairs or 100% due to individual unemployability. Candidate must
attach Veteran’s DD Form 214 or NGB 22 showing character of service, a letter less than 1 year old from the Federal Veterans
Affairs indicating disability and marriage certificate.
• Un-remarried Spouse of Deceased Veteran: Veteran must have died while in service, or later died from service-connected
cause or causes. Candidate must attach Veteran’s DD Form 214 or NGB 22 showing character of service and/or, veterans
death certificate and/or, letter from VA showing disability, and marriage certificate.
Military Service Start Date
• Failure to provide all documentation by the posted closing date may disqualify you from veteran’s preference.
• Veterans' Preference does not apply to State Government Internships or current state employees.
APPLICATION FOR EMPLOYMENT
NORTH DAKOTA STATE ELECTRICAL BOARD
SFN 61953 (3-2021)
Position Applying For
SFN 61953 (3-2021)
Page 2 of 4
EDUCATION AND/OR TRAINING
Type of School
Name of School
Location
(City, State)
Number of
Years Completed
Diploma or
Degree
High School or GED
College or Trade School
College or Trade School
Computer Skills, Related Volunteer Experience, and Other Education, Training and Skills
LICENSE OR CERTIFICATION
License/Certification
State
Profession
License or
Certification Number
Expiration Date
EMPLOYMENT HISTORY
• Employment history to be completed as follows:
o Provide detail – do not use “see resume”.
o Start with your current or last job – include armed forces services and self-employment.
o Any change of job title under the same employer should be considered a separate position.
May We Contact Your Current Employer for a Reference?
☐ No ☐ Yes ☐ Not Applicable
Employer
Telephone Number
Supervisor’s Name
Address
City
State
ZIP Code
Type of Business
Job Title
Dates Employed
Average Hours Worked
per Week
Duties
Monthly Salary
Reason for Leaving or Reason for Considering Leaving if Still Employed
SFN 61953 (3-2021)
Page 3 of 4
Employer
Telephone Number
Supervisor’s Name
Address
City
State
ZIP Code
Type of Business
Job Title
Dates Employed
Average Hours Worked
per Week
Duties
Monthly Salary
Reason for Leaving or Reason for Considering Leaving if Still Employed
Employer
Telephone Number
Supervisor’s Name
Address
City
State
ZIP Code
Type of Business
Job Title
Dates Employed
Average Hours Worked
per Week
Duties
Monthly Salary
Reason for Leaving or Reason for Considering Leaving if Still Employed
Employer
Telephone Number
Supervisor’s Name
Address
City
State
ZIP Code
Type of Business
Job Title
Dates Employed
Average Hours Worked
per Week
Duties
Monthly Salary
Reason for Leaving or Reason for Considering Leaving if Still Employed
Attach Additional Employment History If Needed
SFN 61953 (3-2021)
Page 4 of 4
DIVERSITY
• Our organization 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, applicants are invited to voluntarily self-
identify their gender and their race or ethnicity.
• The information obtained will be kept confidential and may only be used in accordance with the provisions of
applicable laws, executive orders, and regulations. When reported, data will be aggregated and will not identify any
specific individual.
What is your gender?
☐ Female ☐ Male ☐ I decline to answer
Are you Hispanic or Latino?
☐ Yes, I am Hispanic or Latino ☐ No, I am not Hispanic or Latino
What is your race? Select one or more.
☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American
☐ Native Hawaiian or Pacific Islander ☐ White ☐ I decline to answer
I certify that all information contained in this application and any attachments is true and complete to the best of my
knowledge. I understand that any willful misrepresentation, false statement, or omission by me in the application or interview
process will be cause for rejection of my application or termination of my employment. I authorize investigation of all
statements made on this application and any attachments, and I release all persons, companies, and organizations from
liability for providing or receiving such information. I further understand that this employment application and other
employment related documents are not contracts of employment; and, that any oral or written statements to the contrary are
hereby expressly disavowed. A typed name is considered a signature.
Applicant Signature
Date
All information provided is subject to the North Dakota Open Records Law
Equal Opportunity Employer
The state of North Dakota and this hiring agency do not discriminate on the basis of race, color, national origin, sex, genetics,
religion, age, or disability in employment or the provision of services, and complies with the provisions of the North Dakota
Human Rights Act.
Submit completed application to:
North Dakota State Electrical Board Phone: 701-328-9522
PO Box 7335 Fax: 701-328-9524
Bismarck, ND 58507 Email address: electric@nd.gov
Website: www.ndseb.com
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GENERAL INFORMATION (North Dakota State Electrical Board)

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Completed 9 June 2021

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