Killdeer Mountain Manufacturing, Inc.

Killdeer Mountain Manufacturing, Inc.
233 Rodeo Drive | Killdeer, ND 58640-0450
Phone: (701) 764-5651 | Fax: (701) 764-5427

***PLEASE FILL OUT APPLICATION COMPLETELY AND THOROUGHLY***

PERSONAL INFORMATION

Application Date: 5/19/2012

Last Name	First Name	MI
Present Address/Box	City	State Zip Code
Permanent Address/Box	City	State Zip Code
Telephone #	Message #

GENERAL INFORMATION

Position Applying For (be specific):

Date you can start: Salary or Wage Expected:

Check if you are willing to accept: Full Time Permanent Part Time Temporary Shift Work Seasonal

Facility Preference: (Rank in order of Precedence. 1-First Preference, 4 Least Prefered)
Dickinson Killdeer Halliday Hettinger Regent No preference

Are you over the age of 16 years?

EDUCATION/TRAINING

	Name and Location	Course of Study / Major	# of Years Completed	Diploma/Degree
High School
College
Graduate
Vocational
Special certificates/license(s)/equipment operated:
List any other skills/abilities/qualifications/hobbies which should be considered:
MILITARY INFORMATION
Are you a Veteran?		Branch:
Dates of Service: From: To:

WORK HISTORY

Are you presently employed? If yes, may we contact your present employer?
PLEASE COMPLETE THE WORK HISTORY SECTION STARTING WITH YOUR PRESENT OR MOST RECENT JOB (Please be as specific and accurate as possible.)
Company:	City: State:
Supervisor:	Hours Worked Per Week:
Supervisor phone:	Wage: $ Per
Job Title:	Date Started:	(Month/Year)
List specific tasks completed on the job: Machines/Equipment You Have Operated:	Date Ended:	(Month/Year)

	Reason for Leaving:
------------------------------------------------------------------------------------------------------------------------------
Company:	City: State:
Supervisor:	Hours Worked Per Week:
Supervisor phone:	Wage: $ Per
Job Title:	Date Started:	(Month/Year)
List specific tasks completed on the job: Machines/Equipment You Have Operated:	Date Ended:	(Month/Year)

	Reason for Leaving:
------------------------------------------------------------------------------------------------------------------------------
Company:	City: State:
Supervisor:	Hours Worked Per Week:
Supervisor phone:	Wage: $ Per
Job Title:	Date Started:	(Month/Year)
List specific tasks completed on the job: Machines/Equipment You Have Operated:	Date Ended:	(Month/Year)

	Reason for Leaving:
------------------------------------------------------------------------------------------------------------------------------
Please summarize any other work history you may have.

TECHNOLOGY KNOWLEDGE

Select the level of your knowledge in each application:
Application	Knowledge	Type of Software
Word Processing
Powerpoint
Spreadsheet
Dynamics GP
Database
AutoCad
Charting Software
Programming
Other (list in Software Column):

PERSONAL BACKGROUND

The following questions can be answered with a yes or no. Further explanation may be requested.

Are you a US citizen?
If you are not a US citizen, do you have a work authorization or work permit?
Have you ever been convicted of a felony? If so, when?

Have you ever been disciplined for fighting, assaults, or related behavior?
Describe:

Have you ever been discharged or disciplined for violating safety rules?
Have you ever been disciplined for any form of harassment or discrimination?

WORK REFERENCES

Please list below three individuals who can provide work references* (i.e. past employers/professional)*
Name	Address	Telephone #

PLEASE READ *(Check box below upon agreement)*

KMM is an Equal Opportunity Employer.
KMM is an alcohol and drug-free employer.
Employees are hired on an employment-at-will basis.
This application is not a contract or guarantee of employment.
By completing the application, the applicant represents that all information presented in the application is complete and accurate.
If information in the application is found to be false or to have been intentionally omitted, adverse employment action, including termination, may occur.

Confirmation Required:
By checking this box I understand the statements above and certify the information contained in this application is accurate.

Date:

Signature of Applicant:

THANK YOU, KMM appreciates your time and effort in filling out this application in a complete and thorough manner.

233 Rodeo Drive | Killdeer, ND 58640-0450 | Phone: (701) 764-5651 | Fax: (701) 764-5427 | Privacy Policy