Job Application

Wage or Salary Expectation

First Name *
Full Middle Name *
Last Name *
Address *
City, State, Zip *
Preferred Phone *
Second Phone
Email
I am at least 21 years of age *	Yes No
The State of Montana’s Youth Care Facilities Regulations requires that all employees who work with children be at least 21 years old.

First Name *

Full Middle Name *

Last Name *

Address *

City, State, Zip *

Preferred Phone *

Second Phone

I am at least 21 years of age *

Yes
No

The State of Montana’s Youth Care Facilities Regulations requires that all employees who work with children be at least 21 years old.

High School
City/State
Graduated	Yes No
GED	Yes No
The State of Montana’s Youth Care Facilities Regulations requires that all employees have a high school diploma or the equivalent.
College/University (Undergraduate)
City/State
Major
Date Graduated (MM/YY)
Degree/Certificate

College/University (Graduate Studies)
City/State
Major
Date Started (MM/YY)
Date Graduated (MM/YY)
Degree/Certificate
Please list all licenses and certifications, including accrediting agency, number, date received and expiration date (if appropriate).
Please list any other education received, i.e., post-graduate studies, vocational, business school, specialized training, certificates, etc., which pertains to the position(s) sought:

High School

City/State

Graduated

Yes
No

GED

Yes
No

The State of Montana’s Youth Care Facilities Regulations requires that all employees have a high school diploma or the equivalent.

College/University (Undergraduate)

City/State

Major

Date Graduated (MM/YY)

Degree/Certificate

College/University (Graduate Studies)

City/State

Major

Date Started (MM/YY)

Date Graduated (MM/YY)

Degree/Certificate

Please list all licenses and certifications, including accrediting agency, number, date received and expiration date (if appropriate).

Please list any other education received, i.e., post-graduate studies, vocational, business school, specialized training, certificates, etc., which pertains to the position(s) sought:

Begin with your present or last job and list employment history in reverse chronological order. Use additional sheets as needed.

Employer

Address

City/State/Zip

Dates of Employment

Ending Salary

Reason for Leaving

Work Duties

Employer

Address

City/State/Zip

Dates of Employment

Ending Salary

Reason for Leaving

Work Duties

Employer

Address

City/State/Zip

Dates of Employment

Ending Salary

Reason for Leaving

Work Duties

Employer

Address

City/State/Zip

Dates of Employment

Ending Salary

Reason for Leaving

Work Duties

Employer

Address

City/State/Zip

Dates of Employment

Ending Salary

Reason for Leaving

Work Duties

Are you capable of performing the essential functions of the job with or without reasonable accommodations of the position sought?	Yes No
Have you ever been convicted of a felony?	Yes No
Per the State of Montana’s Youth Care Facilities Regulations, if you have been convicted of a felony you are not eligible to work at Intermountain.

Are you capable of performing the essential functions of the job with or without reasonable accommodations of the position sought?

Yes
No

Have you ever been convicted of a felony?

Yes
No

Per the State of Montana’s Youth Care Facilities Regulations, if you have been convicted of a felony you are not eligible to work at Intermountain.

Please provide the name, addresses and phone numbers of the three persons who have knowledge of your experience, skills, abilities and character as they relate to the position(s) sought:
Name
Email Address
Address
City/State/Zip
Phone

Name
Email Address
Address
City/State/Zip
Phone

Name
Email Address
Address
City/State/Zip
Phone
The information on this form will be filed in your personnel record along with resumes or other related supplemental information as proof of your job-related qualifications.

Please provide the name, addresses and phone numbers of the three persons who have knowledge of your experience, skills, abilities and character as they relate to the position(s) sought:

Name

Email Address

Address

City/State/Zip

Phone

Name

Email Address

Address

City/State/Zip

Phone

Name

Email Address

Address

City/State/Zip

Phone

The information on this form will be filed in your personnel record along with resumes or other related supplemental information as proof of your job-related qualifications.

Upload your Cover Letter/Resume
How did you hear about this position? (e.g. Intermountain Staff, Intermountain Website, MT Job Service, Indeed.com, Newspaper Ad)

Upload your Cover Letter/Resume

How did you hear about this position? (e.g. Intermountain Staff, Intermountain Website, MT Job Service, Indeed.com, Newspaper Ad)

As an applicant, I agree to and understand that I must meet minimum age requirements of applicable laws in order to qualify for employment at Intermountain. The minimum age for employment is at least 21 years. Intermountain will conduct investigations including Department of Justice criminal, child protective services, and motor vehicle background checks, verification of prior employment, and/or educational qualifications. By submitting this application, I authorize Intermountain to make these investigations and indicate my awareness that false statements or failure to disclose pertinent information may be sufficient to disqualify me from Intermountain employment, or if employed, may result in my dismissal. Intermountain is an equal opportunity employer and does not discriminate against any applicant because of race, color, religious creed, sex, national origin, ancestry, age, physical or mental disability, related to a bone fide occupational qualification.
Do you Agree to the Statement of Understanding *	Yes No

As an applicant, I agree to and understand that I must meet minimum age requirements of applicable laws in order to qualify for employment at Intermountain. The minimum age for employment is at least 21 years. Intermountain will conduct investigations including Department of Justice criminal, child protective services, and motor vehicle background checks, verification of prior employment, and/or educational qualifications. By submitting this application, I authorize Intermountain to make these investigations and indicate my awareness that false statements or failure to disclose pertinent information may be sufficient to disqualify me from Intermountain employment, or if employed, may result in my dismissal.

Intermountain is an equal opportunity employer and does not discriminate against any applicant because of race, color, religious creed, sex, national origin, ancestry, age, physical or mental disability, related to a bone fide occupational qualification.

Do you Agree to the Statement of Understanding *

Yes
No

Quick Links
Home
Contact Us
Privacy Statement

Get Involved
Donate Now
Careers
Intermountain Blog

Intermountain
3240 Dredge Drive
Helena, MT 59602
Ph: (406) 442-7920
Fax: (406) 442-7949

Join Our Email List

For Email Marketing you can trust.

Personal Information

Education History

Work Experience

Other Information

Employment References

Cover Letter and Resume

Statement of Understanding