***PLEASE FILL OUT APPLICATION COMPLETELY AND THOROUGHLY*** PERSONAL INFORMATION Last Name: * First Name: * MI: Present Address/Box: * City: * State: * Zip Code: * Permanent Address/Box: City: State: Zip Code: Telephone #: * Email: * GENERAL INFORMATION Position Applying For: * (Unsolicited applications will not be accepted) Date you can start: Salary or Wage Expected: Check if you are willing to accept: Full Time Permanent PartTime Temporary Shift Work Seasonal Facility Preference: (Rank in order of Precedence. 1-First Preference, 4 Least Prefered) Dickinson: 1234 Killdeer: 1234 Hettinger: 1234 No preference Are you over the age of 16 years?: YesNo EDUCATION/TRAINING Name and Location Course of Study / Major # of Years Completed Diploma/Degree High School DiplomaGED 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?: YesNo Branch: Dates of Service: From: To: WORK HISTORY Have you ever worked at KMM?: YesNo If yes, please indicate dates of employment and position(s) held: Are you presently employed?: YesNo If yes, may we contact your present employer?: YesNo 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 HourDayWeek2-WeeksMonthQuarterYear Job Title: List specific tasks completed on the job: Date Started: (Month/Year) Date Ended: (Month/Year) Machines/Equipment You Have Operated: Reason for Leaving: Company: City: State: Supervisor: Hours Worked Per Week: Supervisor phone: Wage: Per HourDayWeek2-WeeksMonthQuarterYear Job Title: List specific tasks completed on the job: Date Started: (Month/Year) Date Ended: (Month/Year) Machines/Equipment You Have Operated: Reason for Leaving: Company: City: State: Supervisor: Hours Worked Per Week: Supervisor phone: Wage: Per HourDayWeek2-WeeksMonthQuarterYear Job Title: List specific tasks completed on the job: Date Started: (Month/Year) Date Ended: (Month/Year) Machines/Equipment You Have Operated: 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 No ExperienceBeginnerIntermediateAdvanced Powerpoint No ExperienceBeginnerIntermediateAdvanced Spreadsheet No ExperienceBeginnerIntermediateAdvanced Dynamics GP No ExperienceBeginnerIntermediateAdvanced Database No ExperienceBeginnerIntermediateAdvanced AutoCad No ExperienceBeginnerIntermediateAdvanced Charting Software No ExperienceBeginnerIntermediateAdvanced Programming No ExperienceBeginnerIntermediateAdvanced Other (list in Software Column): No ExperienceBeginnerIntermediateAdvanced PERSONAL BACKGROUND: DUE TO CONTRACT REQUIREMENTS, ALL EMPLOYEES MUST BE A U.S. CITIZEN OR HAVE A PERMANENT RESIDENCY (GREEN CARD) STATUS The following questions can be answered with a yes or no. Further explanation may be requested. Are you a US citizen?: YesNo If you are not a US citizen, are you a permanent resident?: YesNo Have you ever been convicted of a felony?: YesNo If so, when? Have you ever been disciplined for fighting, assaults, or related behavior?: YesNo Describe: Have you ever been discharged or disciplined for violating safety rules?: YesNo Have you ever been disciplined for any form of harassment or discrimination?: YesNo 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 M/F/D. KMM is a 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. KMM prohibits smoking within 25' of all facilities and has a smoke-free and tobacco-free environment. Applications are not held for more than 30 days. * By checking this box I understand the statements above and certify the information contained in this application is accurate. Date: * Signature of Applicant: * AFFIRMATIVE ACTION VOLUNTARY INFORMATION We consider all applications for positions without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria. Not for interview purposes. To be completed by applicant on a voluntary basis. In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated. Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations. Referral Source: —Please choose an option—Job ServiceHero-to-Hire (h2h.jobs)Dakota ConnectionRadio AdvertisementSignJob FairEmployeeFlyer/Bulletin BoardOther Source Indicated: Gender: —Please choose an option—MaleFemale Please select one of the following Equal Employment Opportunity Identification Groups: —Please choose an option—American Indian - Alaskan NativeHispanic - LatinoWhiteNative Hawaiian - Other Pacific IslanderBlack - African AmericanAsian THANK YOU, KMM appreciates your time and effort in filling out this application in a complete and thorough manner.