Position Applying For*

Date

Month/Day/Year

Last name*

First name*

Middle Initial*

Telephone*

Email*

PERSONAL INFORMATION

Street address*

City*

State/Region*

Zip Code*

Have you served in the military

Yes

If you have served in the military, what branch?

Date of discharge

Month/Day/Year

Honorable Discharge

Yes

Attach copy of DD214

OTHER EMPLOYMENT RELATED INFORMATION

Which of the following options would you consider*

FULL-TIME

PART-TIME

Do you claim Native American preference

Yes

If you do claim Indian preference, identify tribe.

Attach verification, if you do identify a tribe.

Are you eligible to Work in the United States

Yes

Were you previously employed by any companies owned and/or operated by the Flandreau Santee Sioux Tribe

Yes

Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation

Yes

Have you ever been convicted of a Felony, pled No Contest in a Felony, been convicted of a Misdemeanor resulting in Imprisonment, fined over $500.00, or been convicted of a Violent Crime involving a Child, Sexual Assault, Molestation, Exploitation, Contact or Prostitution, in the last ten years

Yes

EDUCATION AND TRAINING

High School*

Address*

Have you completed high school

Yes

College or University

College Complete Address

Degree Completed

Major Completed

Degree/Year

Did you complete college

Yes

Trade/Apprentice School

Trade/Apprentice School Address

Trade/Apprentice School Degree

Subjects

Trade/Apprentice School Completion Year

Is Trade/Apprentice School Complete

Yes

List any other Education, Training, Special Skills, Certificates and Licenses that you possess related to this job*

List any Machines or Equipment that you are qualified to operate

List any languages you speak fluently

List any languages you read fluently

List any language you write fluently

UPON OFFER OF EMPLOYMENT YOU WILL BE REQUIRED TO SUBMIT TO A BACKGROUND CHECK & A DRUG AND ALCOHOL SCREENING. REFUSAL TO SUBMIT TO OR FAILURE TO PASS SUCH REQUIREMENTS WILL RESULT IN IMMEDIATE TERMINATION OF EMPLOYMENT OR JOB OFFER.

EMPLOYMENT HISTORY

List your last ten years work experience, beginning with the most recent. This must be completed regardless of Resume/CV submittal:

Employer 1

Name of Employer*

Type of business*

Address*

City*

State*

Zip*

Phone*

Employment Dates*

Starting Title*

Last Title*

Name of Supervisor*

Current or Ending Wage:*

Was Employed*

FULL-TIME

PART-TIME

May we contact

Yes

Reason for leaving*

Brief Description of Duties*

Employer 2

Name of Employer

Type of Business

Address

City

State

Zip

Phone

Employment Dates

Starting Title

Last Title

Name of Supervisor

Current or Ending Wage:

Was Employed

FULL-TIME

PART-TIME

May We contact

Yes

Reason for leaving

Brief Description of Duties Employer

Employer 3

Name of Employer

Type of Business

Address

City

State

Zip

Phone

Employment Dates

Starting Title

Last Title

Name of Supervisor

Current or Ending Wage:

Was Employed

FULL-TIME

PART-TIME

May We Contact?

Yes

Reason for leaving

Brief Description of Duties

Driving Information

Do you have a valid Driver's License

Yes

If yes, State and License Number

Are you insurable

Yes

List any moving violations during the last five years, if any

List any comments or qualifying statements you care to make:

Please read carefully before signing. If you have any questions regarding the following statements, please ask for assistance.

I certify that to the best of my knowledge and belief, the answers given by me in this application are correct and complete. I understand that any false information contained in this application may result in my discharge. I authorize you to communicate with any former employers, school officials and persons named as references. I hereby release employers, schools and individuals from any damage whatsoever resulting from giving such information. I understand that as this organization deems necessary, I may be required to work overtime hours or hours outside a normally defined work week. If employed, I agree that such employment may be terminated at any time and without liability to me for any continuation of salary, wages or employment related benefits.*

I have read and agree to this

Yes

Date*

Full name*

Phone number

Country/Region