APPLICATION FOR EMPLOYMENT
FLATHEAD COUNTY

FLATHEAD COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER
POSITION APPLYING FOR: Nurse Practitioner

INSTRUCTIONS: THIS APPLICATION MUST BE COMPLETED EVEN IF A RESUMÉ IS SUBMITTED. If a question does not apply, enter "NA". Please verify all information prior to submitting the application.
This application form will time out in 3 hours . If you do not complete the form by 12:39 PM you will need to start over.

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Your Information

How may we contact you?
Have you worked for Flathead County before?
Will you accept...
Are you a United States citizen or legally authorized to work in the U.S.?
If required for this position, do you have a valid driver's license?
Is your drivers license a valid Commercial license?
Are any members of your immediate family employees of Flathead County?
Have you ever been convicted of a crime other than a minor traffic violation? *
* A record of criminal conviction will not necessarily bar you from employment.

Bonding Information (if required)

Are you able to be bonded?

Education

High School
Grade Completed:
Received Diploma/GED?
Vo-Tech/Other School Name and Location
Years Completed:
Undergrad College/University Name and Location
Years Completed:
Graduate/Professional School Name and Location
Years Completed:

EXPERIENCE

Begin with your present or most recent job, and list your work experience with emphasis on experience that is relevant to the position for which you are applying. Include military service and any volunteer work that has provided experience that would help you qualify. List each promotion as a separate position. THIS INFORMATION MUST BE COMPLETED EVEN IF A RESUMÉ IS SUBMITTED. IF YOU NEED ADDITIONAL SPACE, PLEASE CONTINUE ON A SEPARATE SHEET OF PAPER, THEN SCAN AND ATTACH IT TO THIS APPLICATION.
Do you want to be informed before we contact your present employer?
Employer #1
Dates Employed
Employer #2
Dates Employed
Employer #3
Dates Employed
Employer #4
Dates Employed
Employer #5
Dates Employed

List All Relevant Skills

PLEASE LIST AT LEAST THREE (3) JOB RELATED REFERENCES


Reference #1
* Write one sentence explaining how you know or have worked with this person, where, when, and for how long.
Reference #2
* Write one sentence explaining how you know or have worked with this person, where, when, and for how long.
Reference #3
* Write one sentence explaining how you know or have worked with this person, where, when, and for how long.
Reference #4
* Write one sentence explaining how you know or have worked with this person, where, when, and for how long.

Veteran's and Handicapped Employment Preference

If you wish to claim Veterans or Handicapped Persons Employment Preference, in accordance with Montana Law, you must complete this form with your application and it must be submitted by the posted closing date. One form must be completed for each position for which you wish to be considered.


I.


II. To claim VETERAN'S EMPLOYMENT PREFERENCE , you must be a U.S. citizen and select one of the options below:
, if
  1. You have been separated under honorable conditions, AND
  2. You have served more than 180 consecutive days of active duty other than for training in the Army, Air Force, Navy, Marines or Coast Guard, or as a member of the Montana Army or Air National Guard and completed your 6 year enlistment with the last 3 years in a Montana Guard unit.
, if
  1. You have been separated under honorable conditions from active duty, AND
  2. You have an established Armed Forces, service-connected disability OR are receiving compensation, disability retirement benefits, or pension from the U.S. Department of Veterans Affairs or military department, OR you have received a Purple Heart.
if the veteran's disability prevents him/her from working.



, if
  1. THE VETERAN lost his or her life under honorable conditions while serving in the Armed Forces, OR THE VETERAN has a service-connected, permanent, and total disability, AND
  2. YOUR SPOUSE is totally and permanently disabled, OR you are the unremarried widow of the father of the veteran
PLEASE ATTACH FORM DD-214 OR NATIONAL GUARD DCSPER FORM 1 IN THE NEXT SECTION


III. You may claim HANDICAPPED PERSONS EMPLOYMENT PREFERENCE as (select one of the options below):
certified by DPHHS.

of a totally (100%) disabled person certified by DPHHS.

If you checked one of the above boxes for Handicapped Persons Employment Act:

Are you a Montana resident?     

If YES, enter date residency was established:
PLEASE ATTACH COPY OF DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES (DPHHS) CERTIFICATION IN THE ATTACHMENTS SECTION

Supporting Document Attachments (resumé, preference certification, training certificates, etc.)

Only image types (JPG, GIF, PNG) and document types (PDF, TXT, DOC, and DOCX) are allowed to be uploaded with this application. If an uploaded document is password protected or contains embedded images hosted on a 3rd party website, the application submission may fail.

If you have more than six (6) documents, multiple documents should be scanned together into one file prior to attachment here.

(45 characters max)
(45 characters max)
(45 characters max)
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All required information must be completed in each section to save/submit your online application. Applications cannot be submitted and will not be accepted after 5:00 pm (Mountain Time) on the closing date.

PLEASE VERIFY ALL INFORMATION IN ALL SECTIONS FOR ACCURACY, SPELLING, AND COMPLETENESS PRIOR TO CONTINUING.

ELECTRONIC SIGNATURE AND CERTIFICATION

By clicking on the 'Continue' button below, you are submitting this form and hereby apply your electronic signature to this application, certifying that you understand and agree to the following:
  • I am the individual named on this application and have filled it out personally, or with assistance from an authorized third-party representative.
  • All information on this and all attached documents is true, correct and complete to the best of my knowledge and contains no willful falsifications or misrepresentations.
  • I am prepared to and can document my claim for preference upon request (if selected in previous section).
  • Falsifications or misrepresentations may disqualify me from consideration for employment or, if hired, may be grounds for termination at a later date.
  • Employers may be contacted as references.