Fillable Form 1.: OFFICE USE ONLY APPLICATION FOR EMPLOYMENT (City of Proctor)

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Form 1.: OFFICE USE ONLY APPLICATION FOR EMPLOYMENT (City of Proctor)

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APPLICATION FOR EMPLOYMENT
City of Proctor
100 Pionk Drive
Proctor, MN 55810
218-624-3641
OFFICE USE
ONLY
Date Received:
Interview:
1.
Title of specific position for which you are applying
2. Date of application 3. Date available for work
4. Last name First name Middle name
5. Are you over the age of 18?
QYes QNo If no, state date of birth
6. Residence phone 7. Business phone 8. County
9. Street address 10. City 11. State and zip code
12. Do you have any relatives working for the City?
QYes QNo If yes, relationship Department
13. Employment condition desired:
(check one) (check one)
QRegular QFull-time
QTemporary QPart-time
14. Have you previously been employed by the City?
QYes QNo If yes, date Position
15. If position involves driving, please indicate driver's license number.
State Class
16. Education. Did you graduate from high school or receive a GED?
QYes QNo School attended
How many years of education have you had? (circle one) 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Name & location of colleges,
universities, technical schools
Did you graduate? Certificate/Degree Courses of Study
17. Employment history. Experience and training ratings are determined by this information - please be complete. List
your present or most recent experience first. Attach additional sheets if necessary.
Employment Firm
Address
Phone # Supervisor
Your Title Supervisor’s Title
Number and type of position you supervised
Principal Responsibilities - Be Complete
Length of Employment
From
month year
To
month year
Hours per week Last salary
Reason for leaving
May we contact your present employer?
QYes QNo
If no, explain
Employment Firm
Address
Phone # Supervisor
Your Title Supervisor’s Title
Number and type of position you supervised
Principal Responsibilities - Be Complete
Length of Employment
From
month year
To
month year
Hours per week Last salary
Reason for leaving
May we contact this employer?
QYes QNo
If no, explain
Employment Firm
Address
Phone # Supervisor
Your Title Supervisor’s Title
Number and type of position you supervised
Principal Responsibilities - Be Complete
Length of Employment
From
month year
To
month year
Hours per week Last salary
Reason for leaving
May we contact this employer?
QYes QNo
If no, explain
18. Relevant current professional memberships, registrations, or licenses. Include date when first issued.
19. Job-Relevant Volunteer and Unpaid W ork Experience
Kind of volunteer activity
(Do not specify organization)
Major Responsibilities # Hours
per month
Years
From To
20. Describe any additional experience or training that qualifies you for this job.
21. CLERICAL APPLICANTS ONLY: Word Processing/Computer Experience
Typing speed WPM Number of Years List software and hardware
22. In accordance with the Immigration Reform and Control Act of 1986, the City of Proctor hires only U.S. citizens
and lawfully authorized alien workers. If hired, you will be required to provide written documentation of citizenship or
legalized alien program. Failure to provide said documentation will result in dismissal.
23. Minn. Stat. Sec. 518.611 Subd. 8, requires employers to obtain information from all new employees regarding court-
ordered child support obligations that are required by law to be withheld from income. If hired, you will be required to
provide such docum entation. Failure to provide said documentation will result in dismissal.
24. Did you serve in the military service of this country and separate under honorable conditions from any branch of the
armed forces of the U.S. after having served on active duty for 181 consecutive days or by reason of disability incurred
while serving on active duty? Q No Q Yes If 'yes', are you a permanent resident of the State of Minnesota? Q No
Q Yes
Describe your duties and any special training:
25. If you are hired for this position, you may be required to undergo a physical examination at this employer's expense
to determine whether or not you are able to perform the duties of this position in an effective and safe manner, and
whether or not accommodations are necessary for you.
26. Give the names of four people other than relatives who can be contacted regarding your qualifications, work habits,
and character.
The City of Proctor does not discriminate on the basis of handicapped status in the admission or access to, or
treatment or employment in, its programs or activities. It is the policy of the City of Proctor to provide reasonable
accommodations to the known physical and mental limitations of qualified handicapped applicants and employees in order
for them to perform the essential functions of the job in question.
THE CITY OF PROCTOR IS AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER
NAME PRESENT ADDRESS TELEPHONE POSITION AND RELATION
TO YOUR W ORK
SIG
NATURE
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.§
43A.39.
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?
Yo
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
with others.
Name To distinguish you from all other
applicants.
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
law.
No We will not be able to determine whether our
selection processes result in unfair
discrimination, or to take affirmative action in
our hiring.
Conviction Record To determine whether we may
legally accept an application from
you to determine whether your
record may be a job-related
consideration.
Yes We will not be able to make determinations
required by law. Failure to provide relevant
conviction information may be grounds for
dismissal.
ALL OTHER INFORMATION ON THE APPLICATION IS PUBLIC; THAT IS, IT MAY BE GIVEN TO ANYONE FOR ANY PURPOSE
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CITY OF PROCTOR ADDENDUM TO
APPLICATION FORM
FOR OFFICE USE ONLY
10 points G
15 points G
VETERANS PREFERENCE POINTS APPLICATION INSTRUCTIONS
Preference points are awarded to qualified veterans and spouses of deceased or disabled veterans to add to their exam
results. Points are awarded subject to the provisions of Minnesota Statutes 43A.11. To be eligible for veterans preference
points, you must:
1. Be separated under honorable conditions from any branch of the armed forces of the United States after having served
on active duty for 181 consecutive days or by reason of disability incurred while serving on active duty, and be a citizen
of the United States or resident alien; or be the surviving spouse of a deceased veteran (as defined above) or the
spouse of a disabled veteran who because of the disability is not able to qualify; AND
2. NOT be currently receiving or eligible to receive a monthly veteran's pension based exclusively on length of military
service.
The information you provide on this form will be used to determine your eligibility for veterans preference points. You are
not required to supply this information, but we cannot award veterans points without it.
YOU MUST SUPPLY A COPY OF YOUR DD214. DISABLED VETERANS MUST ALSO SUPPLY FORM FL-802 OR AN
EQUIVALENT LETTER FROM A SERVICE RETIREMENT BOARD. SPOUSES APPLYING FOR PREFERENCE POINTS
MUST SUPPLY THEIR MARRIAGE CERTIFICATE, THE VETERAN'S DD214 AND FL-802 OR DEATH CERTIFICATE.
If you supply the supporting documentation by separate mail, your name and the position applied for must be included.
ARE YOU APPLYING FOR VETERANS BONUS POINTS? QYES QNO
If you answered "YES", your DD214 or other docum entation must be received no later than seven (7) calendar days
after the application deadline for the position.
VETERANS PREFERENCE POINTS APPLICATION
Veteran QSelf QSpouse If spouse, Veteran's Name:
Branch of Service: Period of Active Duty: From: To:
Rank at Discharge Type of Discharge Date of Discharge Service #
Are you receiving or eligible for a military pension?
QYES QNO
Do you have a compensable service related disability?
QYES QNO
Preference requested: QVeteran QDisabled Veteran
QSpouse of Disabled Veteran QSpouse of Deceased Veteran
Your Preference Points application cannot be considered without supporting documentation (see instructions above).
If the documentation is not attached, it must be received in our office no later than seven (7) calendar days after the
application deadline for the position in order to guarantee that points are awarded in a timely manner.
Supporting documentation: Q is attached Q will be submitted within 7 days of application deadline.
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Form 1.: OFFICE USE ONLY APPLICATION FOR EMPLOYMENT (City of Proctor)

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Completed 14 July 2020

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