j/forms/vetpref.doc (5/12)
VETERAN PREFERENCE QUESTIONNAIRE
(Must be completed by all applicants and submitted with your completed application form.)
City of Bloomington, Minnesota
This questionnaire is to determine your status as a veteran under the Veteran’s Preference Statute, Minnesota Statutes, 43A.11.
Veteran's Preference Statutes provide a 10 point preference to those individuals who have attained a passing score on the
entrance exam and who have received an Honorable Discharge or Separation after serving more than 180 consecutive days in the
military service for purposes other than training. (Fifteen [15] points if a disabled veteran.)
Please check the statement which best describes your current Veteran’s status:
I am not a Veteran (please complete items 1-4 and sign and date the bottom of this form).
I am a Veteran (please complete items 1-10 and sign and date the bottom of this form).
I am the spouse of a deceased Veteran (please complete items 1-10 and sign and date the bottom of this form).
I am the spouse of a disabled Veteran who is unable to use the preference due to the disability (please
complete items 1-10 and sign and date the bottom of this form).
1. Name ______________________________________ 2. S.S. # _______________________________
3. Address ________________________________________________________________________________
(City) (State) (Zip Code)
4. Position for which applying ________________________________________________________________
5. If you achieve the minimum passing rating, do you wish to apply your veteran's preference bonus points?
Yes ____ No ____
6. If a spouse of a deceased or disabled veteran, list veteran's name: ___________________________________
7. Period of active duty: From: __________________________ To: _____________________________
(Do not include short training periods of active duty with a reserve unit. You must have served with a unit that was on
active duty, not one on reserve status.)
8. Branch of Service: _________________________________ Service No.: ________________________
9. Rank at discharge: _______________________ Type of separation or discharge: __________________
(Honorable, General, Etc.)
10. Service connected disability: Type _________________________ Percent ____________________
It is necessary for you to provide the City with a copy of your form DD-214. 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 DD-214 and FL-802 or death certificate.
Your veteran's preference points cannot be considered without supporting documentation. If the documentation is not
attached, it must be received in the Human Resources Office no later than 7 calendar days after the deadline date for the
position.
My supporting documentation: is attached will be submitted within 7 calendar days
I swear that the above statements are true and accurate to the best of my knowledge and belief.
________________________________________ _______________________________________
(Signature) (Date)
Print form out and sign here in ink.
