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Application for Employment
Human Resources
510 4th Street South Fargo, ND 58103  Phone 701.476.7200  Fax 701.476.7261  Jobline 701.280.5799  www.prairie-stjohns.com
MISSION Offering Hope and Healing to Those Suffering from Psychiatric Conditions and Addictions.
VISION To be a Leader in Psychiatric and Addictions Treatment
VALUES Prairie St. John’s was founded on Compassion, Integrity, and Respect, and Acts as a Catholic Health Care Organization by:
• Promoting and Defending Human Dignity • Attending to the Whole Person • Caring for the Poor and Vulnerable
• Stewarding Resources • Promoting the Common Good • Acting on Behalf of Justice
• Abiding by the Ethical and Religious Directives of the Catholic Church
PERSONAL
Name: First
 Middle
 Last
 Previous Name(s)
Address: Street
 City
 State
 Zip
 Daytime Telephone
Position Applying For

Salary Requirements

Type of Employment Seeking

Full
Part Time
PRN/as needed

Hours Preferred

List any times you are not able to work:

Location

Hospital
Fargo Clinic
Moorhead Clinic
Edina Clinic

If Clinical: Prefer working with

Children
Adults
No Preferences

Are you able with or without reasonable accomodations to perform the essential duties of this position?

Yes
No
Date available to begin

Are you at least 18 years old
Yes   No

(Disclosure will not bar consideration for employment. Used to ensure Prairie complies with State/Federal Child labor Laws.)

Are you legally eligible to work in the U.S.?

Yes
No

 Have you ever been convicted of a felony or other crime of dishonesty or breach of trust, or damage to a person or personal property of others?
(Disclosure will not necessarily disqualify you from employment)
Yes   No

If Yes, Explain:
PROFESSIONAL
License type
 Licensing Board
 State
 Number
 Expiration Date
License type
 Licensing Board
 State
 Number
 Expiration Date

How were you referred to Prairie?

Fargo Forum Newspaper

Prairie Website

Careerbuilder.com

Job Service

Minneapolis Star Tribune

Prairie Employee

Career Fair

Walk In

Previously Employed

Other:

List any special certifications you hold:

CPR  MAB/CPI  Parish Nurse
CNA  Medication Admin.

Other:

EDUCATION
Please select the number indicating the total years of schooling you have had:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Type Name of School Address Did you Graduate Type of Degree Field of Study

High School
Business/Vocational Correspondence
College or University
Graduate or Other