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Application for Employment

Application For Employment

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APPLICATION FOR EMPLOYMENT
Nodak Electric Cooperative, 4000 32nd Ave S Grand Forks ND, 58201
Please read before completing the Application for Employment
Nodak Electric Cooperative is an Equal Opportunity Employer. Our objective is to maintain a continuing policy of non-discrimination in employment. You will be considered for employment based upon your qualifications for the position for which you have applied.

Nodak Electric Cooperative, Inc. is the recipient of Federal financial assistance from the U.S. Department of Agriculture (USDA). The USDA prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familiar status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program . (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202)720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue S.W., Washington, D.C. 20250-9410, or call (800)795-3272 (voice) or (202)720-6382 (TDD). USDA is an equal opportunity provider and employer.

Nodak Electric Cooperative is committed to comply with North Dakota law which prohibits smoking within Company premises and within 20 feet of entrances, exits, operable windows, air intakes and ventilation systems of enclosed areas of places of employment. Smoking is also prohibited in any Nodak Electric Cooperative vehicle.
Personal Information
Name*
First Middle Last
Present Address*
Street Address Address Line 2 City State ZIP Code
Is Present Address your Permanent Address?*
- Yes
- No
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Secondary Phone
Email Address*
Enter Email Confirm Email
Position(s) applied for*
Work Type*
- Permanent
- Seasonal/Temporary
- Part Time
Eligibility
Are you eligible for employment in the United States of America?*
- Yes
- No
Are you over the age of 18?*
- Yes
- No
Were you previously employed by Nodak Electric?*
- Yes
- No
When were you last employed by Nodak? (Approximate Date)*
MM slash DD slash YYYY
List any friends or relatives working for Nodak Electric (if none, please state none)*
Start Date:*

If your application is considered favorably, when would you be available to start work?
Where did you learn of this opening?
Education
Highest Level of Completed Education*
Name of Educational Institution*
Field of Study / Major*
Address of Educational Institution
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Number of Years Complete
Did you Graduate?*
- Yes
- No
Would you like to add more information about your education?*
- Yes
- No
Additional Education Information*
Highschool
Name of Highschool
Highschool Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Graduation Date
Military Service Record
Were you in the United States Armed Forces?*
- Yes
- No
What Branch?*
Start of Service*
MM slash DD slash YYYY
Completion of Service*
MM slash DD slash YYYY
Rank Attained*
List General Duties*
List Special Training / Advanced Training*
Special Skills
List any other honors, experiences, skills or qualifications which you feel would especially fit you for work with Nodak Electric Coop. These might include civic interests, public offices, scholastic awards, etc.
Personal References
(Not Former Employers or Relatives)
Personal Reference 1*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Reference Occupation*
Personal Reference 2*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Reference Occupation*
Personal Reference 3
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Reference Occupation
Will your resume include your most recent employment history? (it can be uploaded later in the application)*
- Yes
- No
Previous Employment
(Use successive dates beginning with most recent employer)
Name of Employer*
Address*
Street Address Address Line 2 City State ZIP Code
Type of Business*
Position Held*
Are you currently still working in this position?
- Yes
- No
Starting Date*
MM slash DD slash YYYY
Ending Date*
MM slash DD slash YYYY
Starting Wage*
per*
Ending Wage*
per*
Supervisor Name*
First Last
Supervisor Title*
Reason for Leaving?*
May we contact?*
- Yes
- No
Name of Employer*
Address*
Street Address Address Line 2 City State ZIP Code
Type of Business*
Position Held*
Are you currently still working in this position?
- Yes
- No
Starting Date*
MM slash DD slash YYYY
Ending Date*
MM slash DD slash YYYY
Starting Wage*
per*
Ending Wage*
per*
Supervisor Name*
First Last
Supervisor Title*
Reason for Leaving?*
May we contact?*
- Yes
- No
Would you like to upload your resume and/or cover letter?
Drop files here or

Accepted file types: pdf, doc, docx, txt, , Max. file size: 5 MB, Max. files: 2.
Signature*
The facts stated in my application are true and complete. It is understood that if employed, false statements shall be considered sufficient cause for dismissal. I understand that this application does not by itself create a contract of employment.

NOTIFICATION/RELEASE OF INFORMATION
The purpose of this form is to notify you that a Consumer Report and/or an Investigative Consumer Report may be conducted on you in the course of consideration for employment. I hereby authorize Nodak Electric Cooperative Inc. or any agent of Nodak Electric Cooperative Inc. to contact any and all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts and military services to release information about my background including, but not limited to, information about my employment, education, consumer credit history, driving record, criminal record, and general public records history to the person or company with which this form has been filed. This releases the aforesaid parties from any liability and responsibility for collecting the above information. This release shall remain in effect for the length of my employment. I understand I have the right to obtain a free copy of this consumer report if; (1) Any adverse action/decision is made based on the information in the consumer report, & (2) If the request is made in writing within 60 days of the adverse action. If an Investigative Consumer Report is conducted, I will be notified in writing within three days from request of said report. I believe to the best of my knowledge that all information I have provided is accurate, true and correct and that I fully understand the terms of this release.
Name*
First Middle Last
List any other names used in the last 10 years

Maiden, Nicknames, Aliases, etc
Drivers License Number:*
State Issued*
State
Phone*
Cell Phone*
Current Address*
Street Address Address Line 2 City State ZIP Code
Previous Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
List All cities or towns that where you have lived in the past 10 years*
City, State, Zip and Duration
Have you ever been convicted or pled no contest to a felony?*
- Yes
- No
Please describe location, offenses, dates and disposition:*
Signature*
Date*
MM slash DD slash YYYY

INVITATION TO SELF-IDENTIFY
Nodak Electric Cooperative in accordance with Title 41 Code of Regulations invites all applicants or employees to complete the information listed below. This information will be a valuable assistance in fulfilling Nodak’s federal and state statistical reporting and Equal Opportunity/Affirmative Action requirements and will not be used for or have any effect on any hiring decisions. This information is voluntary and refusal to provide it will not subject you to adverse treatment. The information obtained will be treated in a highly confidential manner and will be used to assist Nodak in the proper and safe placement of all employees including the reasonable accommodations of an individual with a disability.
Name
First Last
Today's Date
MM slash DD slash YYYY
Position:
Gender
- Male
- Female
Race/Ethnicity*
- Native American or Alaskan Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islanders
- Hispanic or Latino (all races)
- White
- Two or More Races
*Definition
American Indian or Alaskan Native – a person having origins in any of the original peoples of North America and South America (including Central America) and who maintains tribal affiliation or community attachment.
Asian – a person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
Black or African American – a person having origins in any of the Black racial groups of Africa.
Native Hawaiian or Other Pacific Islanders – A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islanders.
Hispanic or Latino (all races) – A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin (regardless of race).
White – A person having origins in any of the original peoples of Europe, North Africa or the Middle East.
Two or More Races – All persons who identify with more than one of the five above races.
Disabled:
- Yes
- No
Individual with a Disability - The term “disability,” with respect to the Americans with Disability Act, refers to an individual who has:

o A physical or mental impairment that substantially limits one or more of the major life activities of such individual;
o A record of such an impairment; or
o Being regarded as having such impairment.

If you have a handicap or disability which might affect your performance or create a hazard to yourself or others in connection with the job for which you are applying or are presently performing, please state the following: (1) the skills and procedures you use or intend to use to perform the job notwithstanding the handicap or disability and (2) the accommodation(s) we could make which would enable you to perform this job properly and safely.
Are you a Military Veteran?
- Yes
- No
Veteran Status:(See Description)
- Veteran
- Special Disabled Veteran/Disabled Vietnam Veteran
- Veteran of the Vietnam Era
*Description
Veteran – A citizen of the United States regularly enlisted, drafted, inducted or commissioned, who was accepted for and assigned to active duty in the armed forces of the United States.
Special Disabled Veteran/Disabled Vietnam Veteran– According to the Amendments to the Vietnam Era Veterans Readjustment Assistance Act of 1974, a special disabled veteran is: a veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Veterans’ Administration for a disability (i) rated at 30 percent or more, or (ii) rated at 10 or 20 percent in the case of a veteran who has been determined under section 1506 of this title to have a serious employment handicap, or a person who was discharged or released from active duty because of a service connected disability.
Veteran of the Vietnam Era – A person who has served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released there from with other than a dishonorable discharge, or discharged or released from active duty for a service connected disability during the same period.

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Nodak Electric Cooperative, Inc. is an equal opportunity provider and employer. | © 2023 Nodak Electric Cooperative

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