EMPLOYMENT APPLICATION

Transcription

1 CITY OF DETROIT LAKES EMPLOYMENT APPLICATION 1025 Roosevelt Avenue, PO Box 647, Detroit Lakes, MN (218) POSITION APPLYING FOR: DATE: PERSONAL INFORMATION NAME: (First/Middle Initial/Last) ADDRESS: CITY: STATE: ZIP: MAILING ADDRESS IF DIFFERENT THAN ABOVE: CITY: STATE: ZIP: HOME PHONE # CELL PHONE # WORK PHONE # PREFERRED CONTACT METHOD: HIGH SCHOOL EDUCATION COLLEGE/ UNIVERSITY GRADUATE/PROFFESSIONAL SCHOOL NAME YEARS COMPLETED COURSE OF STUDY DEGREE/DIPLOMA YEAR GRADUATED

2 EMPLOYMENT HISTORY 1. COMPANY NAME: TELEPHONE: POSITION: RATE OF PAY: FROM TO SUPERVISOR: REASON FOR LEAVING: 2. COMPANY NAME: TELEPHONE: POSITION: RATE OF PAY: FROM TO SUPERVISOR: REASON FOR LEAVING: 3. COMPANY NAME TELEPHONE: POSITION: RATE OF PAY: FROM TO SUPERVISOR: REASON FOR LEAVING: PLEASE INDICATE ANY OTHER NAMES BY WHICH FORMER EMPLOYERS KNOW YOU MAY WE CONTACT EACH OF YOUR FORMER EMPLOYERS FOR EMPLOYMENT VERIFICATION? YES NO EMPLOYMENT DESIRED: Full-time Part-time Temporary Seasonal DATE AVAILABLE TO START: NOTE: Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of non-job related medical condition or handicap

3 CLERICAL APPLICANTS LIST ALL OFFICE EQUIPMENT WHICH YOU HAVE EXPERIENCE WITH: LIST ALL COMPUTER SOFTWARE YOU ARE EXPERIENCED WITH: SKILLELABOR SKILLED LABOR APPLICANTS LIST ALL MACHINERY AND EQUIPMENT WHICH YOU HAVE EXPERIENCE OPERATING: OTHER INFORMATION (optional) 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 BETWEEN THE AGES OF 18 AND 70? YES NO If no, please state your date of birth / / HAVE YOU EVER BEEN BONDED ON A JOB? YES NO If so, when and where? HAVE YOU BEEN EMPLOYED BY THE CITY OF DETROIT YES NO LAKES BEFORE? If yes, please state the dates and your position HAVE YOU FILED AN APPLICATION HERE BEFORE? YES NO COULD YOU BE BONDED? YES NO (Getting bonded on a job 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 Detroit Lakes) DO YOU KNOW OF ANY PHYSICAL, MENTAL IMPARIMENT CONDITION THAT COULD INTERFERE WITH YOU PERFORMANCE YES NO ON THE JOB FOR WHICH YOU ARE APPLYING?

4 PLEASE BRIEFLY SUMMARIZE ALL THE REASONS WHY YOU THINK YOU SHOULD BE SELECTED FOR THIS POSITION: Certification and Authorization The above information is true and correct. I authorize the Company to inquire into my education, past employment history, and references as needed to research my qualifications for this position. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of The document(s) provided will be used for the completion of Form I-9. I hereby acknowledge that I have read and agree to the above statements. Applicant s Signature Date

5 THE CITY OF DETROIT LAKES P.O. BOX 647, 1025 ROOSEVELT AVENUE DETROIT LAKES, MINNESOTA EMPLOYMENT BACKGROUND INVESTIGATION As an applicant for employment with the City of Detroit Lakes, you are being asked to provide information about yourself which will be used to evaluate your suitability for employment. The purpose of this background investigation is to review information concerning criminal and non-criminal history which reflects upon the character of the individual. The Detroit Lakes Police Department will be involved in this screening process. This process will include, but not be limited to, incidents of police contact in the areas of domestic abuse, child abuse, sexual misconduct, fraud, theft, abuse of controlled substances, alcohol abuse, driving record, and/or other incidents of information (conviction data, incident data, neighborhood data) which may be relevant during the hiring process for the City of Detroit Lakes positions. The purpose and intended use of this data is to conduct the background inquiries under applicable City of Detroit Lakes policies before offering employment to a prospective applicant. The specific use for each category of data is described below: 1. In order to conduct a criminal history and background check, name(s) by which an applicant is known must be listed. 2. In order to access driver s license data, date of birth must be provided. 3. In order to access criminal history data, date of birth and gender must be provided. 4. Criminal history, background check and driver s license check are required minimum selection standards under applicable City policy in order to determine whether there are any job-related factors which affect the applicant s suitability for employment. This data will be used solely for the above-mentioned purposes. The data will be forwarded to the appropriate City staff and/or consultants as determined necessary for completion of the background investigation. This data may also be used for other purposes necessary for the administration of law, rule or ordinance but will be disseminated only as required by law. You are not legally required to provide the requested information. However, if you do not, the City of Detroit Lakes will be unable to conduct the required background inquiries and will not be able to process your application and the City of Detroit Lakes will not be able to consider you for employment. YOUR FULL NAME: First Middle Last OTHER NAMES YOU HAVE BEEN KNOWN TO USE, INCLUDING MAIDEN NAME: YOUR CURRENT ADDRESS: Street City State Zip OTHER STATES IN WHICH YOU HAVE RESIDED: YOUR BIRTH DATE: Month Day Year DRIVER S LICENSE #: EXPIRATION DATE: I hereby authorize the City of Detroit Lakes to use this information to determine my suitability for employment. Signature Date

6 VETERAN S PREFERENCE APPLICATION 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 fifteen (15) 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. 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) Ten (10) points granted to a non-disabled veteran who meets all of the General Requirements. 2) Ten (10) points granted to spouse (if not remarried) of a deceased veteran who meets all of the General Requirements. 3) Fifteen (15) 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) 15 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.

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8 AFFIRMATIVE ACTION APPLICANT TRACKING FORM Completion of this form is REQUIRED! The City of Detroit Lakes is committed to the concept of equal employment opportunity. In order to help make this commitment a reality, Detroit Lakes has established an affirmative action plan, which requires that the City monitors its applicants to assure the equal treatment to individuals within the protected classes. All information on this form is for the sole use of the Affirmative Action Officer and is NOT available to individuals involved in the selection process. 1. Title of Position applied for: 2. How did you hear about this job opening? 3. Gender 4. Race 5. Did you list any physical disabilities? If yes, please describe what they are 6. Did you list any criminal convictions on this application?