Employment Application

Program, services and employment are equally available to everyone. Please inform Human Resources Department if you require reasonable accommodation for the application or interview.

MRGA

1850 Governors Dr

Casselton, ND 58012

Employment Application Data

*Required Fields

PERSONAL INFORMATION

How were you referred to us?

Position applied for:

Full Name:

Application Date:

Now

Address:

City:

State:

Zip:

Phone:

Cell Phone:

Email:

Date Available to Start:

Now

Date of Birth:

Now

EMPLOYMENT STATUS

Have you ever worked for this company?

Yes No

If yes, when?

Are you legally allowed to work in the United States?

Yes No

Type of employment desired:

Full-Time Part-Time Seasonal

EDUCATION HISTORY

Name & Location of High School:

Did you graduate High School?

Yes No

Name & Location of College:

College - Years attended:

College Degrees completed:

Other College subjects studied:

Trade, Business or Correspondence School:

Trade, Business or Correspondence School - Years attended:

Trade, Business or Correspondence School - Subjects Studied:

Did you graduate Trade, Business or Correspondence School?

Yes No

Summarize Your Special Skills or Qualifications:

Summary:

PERSONAL HISTORY

Residences for the Last 3 Years (Begin with most recent first)

Address 1:

Address 1 From/To:

Address 2:

Address 2 From/To:

Address 3:

Address 3 From/To:

Motor Vehicle Accidents in the Last 3 Years

Date of Accident 1:

Now

Nature and Circumstances of Accident 1:

Were there fatalities in Accident 1?

Yes No

Were there personal injuries in Accident 1?

Yes No

Date of Accident 2:

Now

Nature and Circumstances of Accident 2:

Were there fatalities in Accident 2?

Yes No

Were there personal injuries in Accident 2?

Yes No

Violations of Motor Vehicle Laws

Violation 1:

State in which Violation 1 it occurred:

Fine Amount $ Violation 1:

Violation 2:

State in which Violation 2 it occurred:

Fine Amount $ Violation 2:

Violation 3:

State in which Violation 3 it occurred:

Fine Amount $ Violation 3:

Motor Vehicle License

State of Issuance:

Expiration Date:

Type:

Class:

Endorsements:

Restrictions:

Have you ever been denied a drivers license or had a license revoked or suspended? If "Yes" explain the facts:

List nature and extent of previous driving experience:

Include type of equipment (such as buses, straight trucks, tractor trailers and types of trailers

EMPLOYMENT HISTORY:

3 Years Previous Employment History (Begin with most recent)

Company 1

Company Name:

Dates of Employment:

Company Address:

City:

State:

Zip:

Company Phone:

Supervisor:

Title:

Positions(s) Held:

Responsibilities:

Was this job designated as a safety sensitive function requiring alcohol and controlled substance testing?

Yes No

Reason for Leaving:

Company 2

Company Name:

Dates of Employment:

Company Address:

City:

State:

Zip:

Company Phone:

Supervisor:

Title:

Positions(s) Held:

Responsibilities:

Was this job designated as a safety sensitive function requiring alcohol and controlled substance testing?

Yes No

Reason for Leaving:

Company 3

Company Name:

Dates of Employment:

Company Address:

City:

State:

Zip:

Company Phone:

Supervisor:

Title:

Positions(s) Held:

Responsibilities:

Was this job designated as a safety sensitive function requiring alcohol and controlled substance testing?

Yes No

Reason for Leaving:

Certification:

Checking the box certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

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