The City has the right to verify information provided in the application. I may be discharged if there are any
misrepresentations on this application or my resume or made by me in an interview which may be discovered now or
anytime in the future. False information or misrepresentation may also subject me to the penalty provisions of M.S.§
In connection with this application for employment, I authorize the City of Proctor and any agent acting on its behalf to
conduct an inquiry into any job-related information contained in this application, including, but not limited to, my
records maintained by an educational institution relating to academic performance such as transcripts. Moreover, I
hereby release the City of Proctor and any agent acting on its behalf from any and all liability of whatsoever nature
by reason of requesting such information from any person.
QYES QYES, but not present employer until job is offered. QNO (W e may be unable to hire you without this information)
I declare that any statement in this application or information provided is true and complete and hereby acknowledge
that I have read and I understand the information below.
DATE SIGNATURE (Do not print)
IMPORTANT FACTS ABOUT INFORMATION ON YOUR APPLICATION
This application is to assist in the process of referring you for possible employment. Certain information requested on the
application is private; that is, it may be released only to you or to agencies where you may be considered for employment
(to comply with M.S. 13.43, Subd. 2). If you become employed by the City, the data will be available to the Department of
Finance, the Internal Revenue Service, and the Social Security Administration for payroll and tax purposes. If you disagree
with the data we have about you, notify the City Clerk/Human Resources Assistant by letter.
Private Data Why We Ask For It Are You Legally Obliged
What May Happen If
To Provide It?
u Don’t Provide It
Social Security Number To distinguish you from all other
applicants and to make
procession more efficient
No In most cases, nothing. However, it will help
to ensure that your records are not confused
Name To distinguish you from all other
Yes Failure to provide information may be cause
for rejecting an application.
Date of Birth (when requested on
a separate form)
To conduct a check of criminal
records for certain positions
No Failure to provide information may be cause
for rejecting an application.
Address To be able to send you notices. Yes Failure to provide information may be cause
for rejecting an application
Home Telephone To be able to contact you to
determine availability for interview
and to notify you when we need
you to work on short notice.
No We may not be able to employ you in certain
jobs where you may be required to come to
work on short notice.
Sex, Racial/Ethnic Group,
Handicapped Status, Veteran
Status (This information is
requested on a separate form)
To be able to make Equal
Opportunity reports as required by
No We will not be able to determine whether our
selection processes result in unfair
discrimination, or to take affirmative action in
Conviction Record To determine whether we may
legally accept an application from
you to determine whether your
record may be a job-related
Yes We will not be able to make determinations
required by law. Failure to provide relevant
conviction information may be grounds for
ALL OTHER INFORMATION ON THE APPLICATION IS PUBLIC; THAT IS, IT MAY BE GIVEN TO ANYONE FOR ANY PURPOSE
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