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Langdon Prairie Health is an equal opportunity employer and will not discriminate based on race, national origin, color, religion, age, sex, sexual orientation, disability, military status, or marital status. Langdon Prairie Health is an at-will employer, and this application is not a contract of employment nor is it intended to be a contract of employment. This application does not obligate Langdon Prairie Health in any way if the applicant is hired by the hospital.

Your Information

Position applying for: *

First name: *

Last name: *

Email: * (invalid email)

Phone:

Address: *

City: *

State: *

Zip code: *

Previous employment at Langdon Prairie Health? *

If yes, what position(s) did you hold and when?

HIGH SCHOOL EDUCATION:

Name and location: *

Years completed: *

Did you get your diploma? *

COLLEGE/VOCATIONAL OR TECHNICAL SCHOOL:

School #1 - Name and location:

Course of Study:

Degree:

School #2 - Name and location:

Course of Study:

Degree:

LICENSURES AND CERTIFICATION: (if applicable to position)

Title #1:

Number:

Expiration:

Title #1:

Number:

Expiration:

WORK EXPERIENCE: (list past and present employment, beginning with most recent

Company name #1:

Address

Phone

Position held:

Primary duties:

Reason for leaving:

Date employed from:

Date employed to:

Company name #2:

Address

Phone

Position held:

Primary duties:

Reason for leaving:

Date employed from:

Date employed to:

Company name #3:

Address

Phone

Position held:

Primary duties:

Reason for leaving:

Date employed from:

Date employed to:

RELATED SKILLS, EDUCATION &/OR ACTIVITIES: (if applicable to position applying for)

REFERENCES

Please list 2 work references & 1 personal reference

Name #1:

Phone:

Address:

Relationship:

Name #2:

Phone:

Address:

Relationship:

Name #3:

Phone:

Address:

Relationship:

Please upload your resume if available

The facts set forth in this application are true and complete to the best of my knowledge. I understand that if employed, any false statement on this application may result in dismissal.

I understand it is Langdon Prairie Health policy to verify past employment, check work-related references, licensure verification and where regulated by state statute, conduct criminal background checks on prospective employees.

I consent to the release of information concerning my capacity and/or all aspects of prior job performance by employers, educational institutions, law enforcement agencies, state licensing boards and other individuals and agencies to duly accredited investigators, human resource staff and other authorized employees of Langdon Prairie Health. I waive any action against Langdon Prairie Health or former employers based on statements made during these investigations.

By pressing the submit button below I hereby certify that I have read and understand the above statement and that the information provided herein is complete and factual.

909 2nd St., Langdon, ND 58249 | (701) 256-6100

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Your Information

HIGH SCHOOL EDUCATION:

COLLEGE/VOCATIONAL OR TECHNICAL SCHOOL:

LICENSURES AND CERTIFICATION: (if applicable to position)

WORK EXPERIENCE: (list past and present employment, beginning with most recent

RELATED SKILLS, EDUCATION &/OR ACTIVITIES: (if applicable to position applying for)

REFERENCES

Please upload your resume if available