School, Address	Did you Graduate?	Certificate/Diploma/Degree Earned	Major/Minor
High School	Yes No GED		N/A
College/University/Technical School	Yes No
College/University/Technical School	Yes No
College/University/Technical School	Yes No

Current/ Most Recent Employer	Dates of Employment: From To Total Years:    Total Months:
Address City State Zip Code MN ND AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MS MO MT NE NV NH NJ NM NY NC OH OK OR PA RH SC SD TN TX UT VT VA WA WV WI WY	Reason for Leaving:
Position Title:	Last Salary:
Supervisor's Name:	May we contact this person? Yes  No
Supervisor's Title:	Telephone:
Primary Responsibilities:

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Prior Employer	Dates of Employment: From To Total Years:    Total Months:
Address City State Zip Code MN ND AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MS MO MT NE NV NH NJ NM NY NC OH OK OR PA RH SC SD TN TX UT VT VA WA WV WI WY	Reason for Leaving:
Position Title:	Last Salary:
Supervisor's Name:	May we contact this person? Yes  No
Supervisor's Title:	Telephone:
Primary Responsibilities:

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Prior Employer	Dates of Employment: From To Total Years:    Total Months:
Address City State Zip Code MN ND AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MS MO MT NE NV NH NJ NM NY NC OH OK OR PA RH SC SD TN TX UT VT VA WA WV WI WY	Reason for Leaving:
Position Title:	Last Salary:
Supervisor's Name:	May we contact this person? Yes  No
Supervisor's Title:	Telephone:
Primary Responsibilities:

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Driver's License:	Yes No   State: MN ND AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MS MO MT NE NV NH NJ NM NY NC OH OK OR PA RH SC SD TN TX UT VT VA WA WV WI WY
CDL License = A, B or Both	A  B  Both

  Describe any other past training or experience - paid or unpaid - that has prepared you for this job. Please be specific.

Indicate which software programs you are familiar with:

Microsoft WordMicrosoft Access Microsoft ExcelAdobe Reader Microsoft PowerPoint

Other:

List all machines and equipment which you have experience operating.

Do you have a social security number?	Yes  No
If not, have you tried to get one and failed?	Yes  No
If not, do you have an Alien Registration Receipt Card?	Yes  No
Can you legally accept permanent employment in the United States?	Yes  No
Are you over the age of 18?      If not, please state your birth date	Yes  No
Have you ever been bonded on a job?	Yes  No
If so, when and where?
Could you be bonded?       (Getting bonded can be difficult for persons who have been convicted of certain criminal offenses. This information will not necessarily preclude you from consideration for employment with the City of Moorhead.)	Yes  No
Do you have access to adequate transportation available to get you to get to work on time daily?	Yes  No
Is there any reason why you cannot be at work on time every day?	Yes  No

Please briefly summarize all the reasons why you think you should be selected for this job.

In accordance with the Minnesota Government Data Practices Act, the City of Moorhead is required to inform you of your rights as they pertain to private data collected from you. Private data is that information which is available to you, but not to the public. Some personal information we collect about you is private.

Minnesota Statutes 13.01 to 13.87, Government Data Practices, require that you be informed that the following personal information which you are asked to provide on the Employment Application is considered private data:

1. *Name
2. Home address
3. Home phone number
4. Age group
5. Disability type
6. Racial/ethnic group

*Names become public when certified as a “finalist” - see below.

We ask this information for the following reasons:

1. To distinguish you from all other applicants and identify you in our personnel files.
2. To help us to be sure that you are the individual who makes the application.
3. To help us to contact you when more information is required, when we send you notices and/or when we schedule you for interviews.
4. To see if you meet the minimum age requirements (if any).
5. To conduct proper background investigations needed when applying for a position.
6. To determine whether or not any conviction record may be a job-related consideration affecting your suitability for the position you applied for.
7. To enable us to ensure your rights to equal opportunities.
8. 8. To meet federal and state reporting requirements.

Data supplied by you may be used for such purposes as may be determined to be necessary in the administration of personnel in the City of Moorhead and in the administration of personnel policies, rules and regulations.

FURNISHING RACE, SEX, AGE GROUP, AND DISABILITY DATA IS VOLUNTARY, BUT REFUSAL TO SUPPLY OTHER REQUESTED INFORMATION WILL MEAN YOUR APPLICATION FOR EMPLOYMENT MAY NOT BE CONSIDERED.

Private data is available only to you and to other persons in the City Offices who have a justified need for the data. Public data is available to anyone requesting it and consists of all data furnished in the employment process which is not designated in this notice as private data.

Names of applicants remain private except when certified as eligible for appointment to a vacancy or when applicants are considered by the City to be finalists for a position with the City. “Finalist” means a person who is selected to be given an interview with the City Manager, or his/her designee, as a final step prior to selection.

By my signature below, I certify that I have read (or had read to me) the information printed above and understand its meaning.

I further certify that the facts set forth in the above Application for Employment are true and correct.

I understand that, if employed, false statements on the application shall be considered sufficient cause for dismissal.

Unless otherwise indicated above, the City of Moorhead is hereby authorized to contact my former employers for information concerning my employment, ability, experience and behavior on the job.

I understand that nothing in this employment application is intended to lead to or create an employment contract between the City of Moorhead and myself.

I further understand and agree that the employment relationship that may result from my application may be terminated at any time by the City or myself.

I UNDERSTAND AND AGREE TO TERMS LISTED ABOVE	DATE:

The following summarizes the major points of M.S. 43A.11 as amended, which now governs the granting of veteran’s preference at both the state and local levels. This chapter may be ordered from the Documents Section, Department of Administration, 117 University Avenue, St. Paul, Minnesota 55155.

 

A. General Requirements: Applicants must meet all of the following to qualify for any preference points:

1)       Meets qualifications of position and/or received final passing score in the exam process without addition of preference points.

2)       Separated under honorable conditions from any branch of the armed forces of the United States.

3)       Served on active duty for 181 consecutive days or more or was separated by reason of disability incurred while serving on active duty.

4)       Is a United States citizen.

5)       Is not eligible for or currently receiving a monthly veteran’s pension benefit based on length of military service.

 

B. Points Granted:

1)       Five (5) points granted to a non-disabled veteran who meets all of the General Requirements.

2)       Five (5) points granted to spouse (if not remarried) of a deceased veteran who meets all of the General Requirements.

3)       Ten (10) points granted to a disabled veteran who meets all of the General Requirements if:

a)       the veteran has a compensable service-connected disability as judged by the United States Veterans Administration or by the Retirement Board of the Branches of the Armed Forces.

b)      the disability exists at the time preference is claimed.

4)       10 points granted to the spouse of a disabled veteran who meets all of the General Requirements and the requirements listed in 3 above, but who is unable to qualify because of the disability.

DIRECTIONS: Complete either item number 1 or item number 2 below; sign, and insert this form into the completed

application form.

 

1. I am eligible to receive preference points. I certify that I am eligible to receive the preference so declared

based on my understanding of the provisions of Minnesota Statutes 43A.11. I further certify that I served in

the following branch of the armed forces of the United States: on active

duty for 181 or more consecutive days from: to  

 

and was separated under:

                           Honorable Conditions

                           disability incurred while serving on active duty

(Please include a copy of your DD #214)

 

I am not eligible for or currently receiving a monthly veteran’s pension benefit based exclusively on length of

military service.

 

If I have declared ten (10) preference points, I hereby certify that I am a disabled veteran with a compensable

service connected disability as judged by the U.S. Veteran’s Administration or by the retirement boards of the

branches of the armed forces, that the disability exists at this time, and that the disability would not, to the best of

my knowledge, prevent me from completely performing essential functions of the position I have applied for.

 

DATE:
NAME:

 

 

2. I do not claim veteran’s preference points.

DATE:
NAME:

Please return completed form with application.

 

 

Instructions

The policy and intent of the City of Moorhead is to provide equal employment opportunity for all persons regardless of

race, color, creed, religion, national origin, marital status, disability, sex, age, or status with regard to public assistance.

INDIVIDUALS WILL SEPARATE THIS SHEET FROM YOUR APPLICATION OTHER THAN THOSE WHO MAKE EMPLOYMENT DECISIONS AND THE REQUESTED INFORMATION WILL IN NO WAY AFFECT YOU AS AN INDIVIDUAL APPLICANT. This information will be used to determine the effectiveness of our recruiting efforts in reaching all segments of the population and in validation of our selection methods.

Although providing this information is voluntary, it is important that all applicants answer these questions so that we may take steps to prevent discrimination in the selection of employees for the City of Moorhead.

Which sex are you?  Male  Female

Of the following, what racial/ethnic group do you consider yourself?

          American Indian or Alaskan Native

          Black (Non-Hispanic Origin)

          Hispanic

          White (Non-Hispanic Origin) 

          Asian or Pacific Islander

 

Do you consider yourself to be disabled:   Yes   No

    (Disabled means any person who has a physical or mental impairment that materially limits one or more major life

    activities, has a record of such an impairment, or is regarded as having such an impairment.)

 

How did you learn about this job?

              Forum Want Ad

              Minnesota State Employment Service

              North Dakota State Employment Service

              NDSU Placement Office

              Concordia College Placement Office

              MSUM Placement Office

              Minnesota State Community and Technical College-Moorhead

              Other Website (please list)    

              Other Source (please list)    

 

Thank you for your assistance