Dickinson, North Dakota
(701) 483-5000
St. Luke’s Home
Park Ave Villa
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Dickinson, North Dakota

Employment Application

Employment Application

Employment Application
Have you been employed here before?
Can you provide proof you are eligible to work in US if offered employment?


Availability to work:


Do any of your friends work here?
Do any of your relatives work here?


Are you subject to recall?


Have you ever been convicted of abuse of persons in your care?
Have you ever been convicted of a felony?


Personal References



Employment History

Starting with present or last job, list all jobs held including military service assignments.

Most Recent/Current Employer

Dates of Employment

Second Most Recent

Dates of Employment

Third Most Recent

Dates of Employment




Completion of this part of the form is voluntary. All information provided will remain confidential and will not affect your application or potential for employment. We are required by law to collect this information for equal opportunity employment purposes. If skipping, scroll to the bottom to submit employment application.

Race/Ethnicity (Please select one option with which you most identify)


Having made an application for employment with St. Luke's Home and desiring them to be informed as to my previous record and character, I hereby authorize St. Luke's Home to investigate my past record and ascertain any and all information which may concern my record and character, whether having the same record or not and release my present and past employers, references and all persons whomsoever from any damage because of furnishing said information.

I certify that the answers given on this form are true and complete to the best of my knowledge.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

Applications are considered active for 90 days. This application is retained for one year after submission.


Our tobacco-free policy is established to do:
Protect the health and safety of all Employees and Visitors to the Workplace Property.
Reduce the exposure of Employees and Visitors to smoking, secondhand smoke and the use of other Tobacco Products.
Establish a standard of healthy, tobacco-free behavior.
Encourage employees who currently use tobacco products to utilize available cessation.