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409 S 3rd St, Strasburg, ND

701-336-2651

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Online Application

Welcome to Our Online Application

We’re excited that you’re considering joining the Strasburg Care Center team. This application is your first step toward becoming part of a compassionate, dedicated community that values every individual’s contributions. Please take a few moments to complete the form below. If you have any questions along the way, don’t hesitate to reach out-we’re here to help.

1Personal Information

2Work Desired

3Education

4Employment Record

Date of Application

MM slash DD slash YYYY

Date Available

MM slash DD slash YYYY

Personal Information

Name(Required)

First Middle Last

Email(Required)

Present Address(Required)

Street Address City State ZIP Code

Phone(Required)

Permanent Address (If different than present address)

Street Address City State ZIP Code

Phone

If you cannot be reached at above phone number, where may we contact you?

Name of Person

Phone

Employment Desired

Type of Work Desired

Shift

Salary

First choice, second choice, third choice.

Will You Accept Employment of:

Full Time

Part Time

Temporary

Are You 18 Yrs. of Age or Older?

Yes

Are You Employed Now?

Yes

May We Contact Your Present Employer?

Yes

How Did You Learn Of This Opening?

Education

Highest Grade Completed

Scholastic Honors Received

Grammar or Grade School

Grammar School

Name of School

Location

Cources Taken

Completes (yes / no)

Type of Degree

High School

Name of School

Location

Cources Taken

Completes (yes / no)

Type of Degree

College

Name of School

Location

Cources Taken

Completes (yes / no)

Type of Degree

Vocational or Business

Vocational School

Name of School

Location

Cources Taken

Completes (yes / no)

Type of Degree

Professional Education

Name of School

Location

Cources Taken

Completes (yes / no)

Type of Degree

Laboratory or X-Ray Training

Name of School

Location

Cources Taken

Completes (yes / no)

Type of Degree

Extracurricular Activities While in School

Member of Professional Organizations

Honors Received, Volunteer or Community Service or Other Qualifications You Have Which You Feel Are Related to the Position for Which You Are Applying:

Were you in the U.S. Armed Forces?

Yes

If yes, what branch?

Dates of Duty: From

Dates of Duty: To

Rank at Discharge

Professional Licenses and/or Certifications

Type

Organization or State Issued

Date Issued

Number

Employment Record

Employment Record (list last or present position first)

Name

Address

City / State / Zip

Supervisor

Phone

Start / End Dates

Salary State / End Amount

Position and Duties

If your former employment references, education or military service are under a name other than indicated on front of application, please indicate below.

First Middle Last

Have you ever been convicted of a crime?

Yes

If Yes, for what, when and where?

Use this space to give us further information which will assist us in placing you, including at least two personal references not related to you, whom you have known at feast one year.

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