Employment Application Form

We welcome you as an applicant for employment with the City of Hendrum. It is the City of Hendrum’s policy to provide equal opportunity in employment. The City of Hendrum will not discriminate on the basis of race, color, creed, age, religion, national origin, marital status, disability, sex, sexual orientation, familial status, status with regard to public assistance, local human rights commission activity or any other basis protected by law.

Please furnish complete information, so we may accurately and completely assess your qualifications. You may attach any other information which provides additional detail about your qualifications for employment in the position you seek. Please refer to the Applicant Data Practices Advisory for information regarding what is considered public and private information as an applicant, and if you are selected for the position, as an employee.

The City of Hendrum accommodates qualified persons with disabilities in all aspects of employment, including the application process. If you believe you need a reasonable accommodation to complete the application process, please contact the City Clerk’s office at (218) 861-6210.

Full Name*

First NameLast Name

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

Confirmation Emailexample@example.com

Wage expectations*

Salary or Hourly?*

Referral source

Are you currently employed?*

YESNO

Date available for work*

Date

Are you over the age of 18?*

YESNO

Are you legally eligible to work in the United States in the position for which you are applying? Proof of citizenship or work eligibility will be required as a condition of employment*

YESNO

Do you have a current and valid driver's license*

YESNO

EDUCATION

Highest level of education completed:*

Please complete the appropriate sections

	Name & Location of School	Number of Years Attended	Did You Graduate?	Degree or Certification
GED / High School
Trade School
College
Graduate

WORK HISTORY Please list your four most recent employers, list the most recent first

1. Employer

Employer's Name (Most current)*

Address & location of business*

Your title*

May we contact this employer?*

YESNO

Supervisor's name*

First and Last Name

Phone number*

Start date*

MonthDayYear

End date

MonthDayYear

Wages START:*

Salary or Hourly*

Wages END:*

Salary or Hourly*

Work performed:*

Reason for leaving*

2. Employer

Employer's Name (Second most recent)*

Address & location of business*

Your title*

May we contact this employer?*

YESNO

Supervisor's name*

First and Last Name

Phone number*

Start date*

MonthDayYear

End date

MonthDayYear

Wages START:*

Salary or Hourly*

Wages END:*

Salary or Hourly*

Work performed:*

Reason for leaving*

3. Employer

Employer's Name (Third most recent)

Address & location of business

Your title

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Start date

MonthDayYear

End date

MonthDayYear

Wages START:

Salary or Hourly

Wages END:

Salary or Hourly

Work performed:

Reason for leaving

4. Employer

Employer's Name (Fourth most recent)

Address & location of business

Your title

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Start date

MonthDayYear

End date

MonthDayYear

Wages START:

Salary or Hourly

Wages END:

Salary or Hourly

Work performed:

Reason for leaving

ADDITIONAL INFORMATION

Do you have a U.S. military service record?

YESNO

Do you wish to apply for Veterans' Preference points?

YESNO

Veterans’ Preference

COMPLETE THIS FORM ONLY IF YOU ARE CLAIMING VETERANS’ PREFERENCE

NOTE: COPY OF “MEMBER COPY 4” VETERAN’S DD214, OR OTHER DOCUMENTATION VERIFYING SERVICE, MUST BE ATTACHED

(Veteran is defined by Minn. Stat. § 197.447)

You must submit a PHOTOCOPY of your “Member Copy 4” of your DD214 or other documentation verifying service to substantiate the services information requested on the form. Claims not accompanied by proper documentation will not be processed. For assistance in obtaining a copy of your “member Copy 4” of your DD214, or other documentation verifying service, contact your County Veterans’ Service Office.

The City of Hendrum operates under a point preference system, which awards points to qualified veterans to supplement their application. Ten (10) points are granted to non-disabled veterans on open competitive examinations; Fifteen (15) points are awarded if the veteran has a service connected compensable disability as certified by the U.S. Department of Veterans Affairs (USDVA).

To qualify for preference for a competitive exam, you must have earned a passing score and been 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, or after having served the full period called or ordered for federal, active duty and be a United States citizen or resident alien. Veteran’s preference may be used by the surviving spouse of a deceased veteran, who died on active duty or as a result of active duty, and by the spouse of a disabled veteran who is unable to qualify because of the disability.

To qualify for preference on a promotional exam, a veteran must have earned a passing exam score and received a USDVA active duty service connected disability rating of 50% or more. For a promotional exam, a qualified disabled veteran is entitled to be granted five (5) points. Disabled veterans eligible for such preference may use the five points preference only for the first promotion after securing employment with the City of Hendrum.

Claims must be made on the form below and submitted with your application by the application deadline of the position for which you are applying. If the “Member Copy 4” DD214, or other documentation verifying service, is submitted to our office separate from this sheet, please attach a note with it indicating the position for which you are applying and your present address.

VETERAN (10 points): Honorably discharged veteran?

YESNO

DISABLED VETERAN (15 points): Have you ever been promoted within the City of Hendrum employment?

YESNO

SPOUSE OF DECEASED VETERAN (10 points or 15 if the veteran was disabled at the time of death): Have you remarried?

YESNO

SPOUSE OF DISABLED VETERAN (15 points)

YES

How does Veteran's disability prevent performance of a stated job "requirement?" Due to the veteran's service-connected disability the veteran is unable to qualify for this position because (be specific):blanks .

Upload supporting documentation, click Choose File

Type signature*

Date*

Date

List job-related accomplishments, projects, and awards. (You may exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.)

List any additional information you would like us to consider:

REFERENCES List three professional references, (business or work, not relatives) that you have known for at least one year. List at least one previous supervisor.

1. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

2. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

3. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

AUTHORIZATION: I certify that all information I have provided in this application for employment is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or if employed, will be grounds for dismissal, regardless of length of employment or when the misrepresentation or omission is discovered.

I acknowledge that I have received a copy of the job description summary for the position for which I am applying. I further acknowledge my understanding that employment with the City of Hendrum is “at will,” and that employment may be terminated by either the City of Hendrum or me at any time, with or without notice.

With my signature below, I am providing the City of Hendrum authorization to verify all information I provided within this application packet, including contacting current or previous employers. However, I understand that if, in the Employment Experience section I have answered “No” to the question, “May we contact your current employer?,” contact with my current employer will not be made without my specific authorization.

I further understand that criminal history checks may be conducted (after I have been selected for an interview, in the case of non-public safety positions) and that a conviction of a crime related to this position may result in my being rejected for this job opening. I also understand it is my responsibility to notify the City of Hendrum in writing of any changes to information reported in this application for employment.

By entering your name, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree

You must agree to accept the terms of the document in order to submit an application.

Type signature*

Date*

Date

If you would like to upload your resume, click Choose File. (not required)

If you would like to upload a cover letter, click Choose File. (not required)

Applicant Data Practices Advisory

The Minnesota Government Data Practices Act (Minn. Stat. §§ 13.01 – 13.90) includes two sections affecting applicants seeking employment with the City of Hendrum. First, under “Rights of Subjects of Data” (Minn. Stat. § 13.04), when an applicant is asked to provide information about him/herself, the City must advise you of:

· The purpose and intended use of the data;

· Whether you may refuse or are legally required to supply the requested data;

· Any known consequences arising from your supplying or refusing to supply the data; and

· The identity of other persons or organizations authorized by State of Federal law to receive the data you provide.

Second under “Personnel Data” (Minn. Stat. §13.43) the following data on you as an applicant for employment by a public agency is automatically public:

· Your veteran’s status;

· Your job history;

· Your education and training;

· Your relevant test scores;

· Your rank on our eligibility list; and

· Work availability.

As an applicant, your name is considered private until you are certified as eligible for appointment to a position or are considered by the appointing authority to be a finalist for a position in public employment.

If you are hired, the following additional data about you will be considered public information:

· Your name;

· Your employee identification number (which is not your Social Security number);

· Your actual gross salary, contract fees, salary range, and actual gross pension;

· The value and nature of employer paid benefits;

· The basis for and the amount of any added remuneration, including expense reimbursement, in addition to your salary;

· You job title, bargaining unit (if applicable) and job description;

· The dates of your first and last employment with us;

· The status of any written complaints or charges against you while you work for the City of Hendrum, regardless whether or not they have resulted in disciplinary action, the final disposition of any disciplinary action and supporting documentation;

· You work location and work telephone number;

· Your education and training background;

· Work-related continuing education;

· Honors and awards you have received;

· Payroll timesheets or other comparable data that are only used to account for your works time for payroll purposes: except to the extent that release of time sheet data would reveal employee’s reasons for the use of sick or other medical leave or other non-public data;

· Your previous work experience;

· The “complete” terms of any settlement agreement (including buyout agreements) except that the agreement must include the specific reasons if it involves the payment of more than $10,000 of public money; and

· Your badge number. This data is private if the candidate is applying for or is hired for an undercover law enforcement position.

All data concerning you which is placed in your personnel file and which is not addressed in statute as public data (see above listing) is private data. This private data will be available to you and those members of city staff needing it to process city records. In addition, the following persons or organization are authorized by state and federal law to receive this data if they so request in certain circumstances:

· The Bureau of Census;

· Federal, State and County Auditors;

· The State Department of Public Welfare;

· The Department of Human Rights;

· Federal Officials investigating compliance of Affirmative Action and Equal Employment Opportunities;

· Labor organizations and the Bureau of Mediation Services;

· Data may also be made available through court order.

With the exception of the optional data requested, the data you provide is needed to identify you and you assist in determining your suitability for the position for which you are applying. The optional data is used in summary form by the city’s Affirmative Action Program to monitor protected class employment and meet federal, state and local reporting requirements.[1] Furnishing the optional data requested about you in voluntary.

NOTICE REGARDING SOCIAL SECURITY NUMBER: This information will be used for payroll taxes, insurance purposes, and retained in the employee’s data record.

NOTICE TO MINORS: Minors from whom private data or confidential data is collected have the right to request that parental access to the private data be denied.

If you have any questions regarding your rights as a subject of data, please contact the City of Hendrum Clerk’s Office at PO Box 100, Hendrum, MN 56550. This information is subject to change consistent with subsequent amendments to the Minnesota Government Data Practices Act.

Application for Employment