Application for City of Madelia

Title of Position:

Date of Application:

Date Available for Work:

Name:

First Middle Last

Email*

Cell Phone:

Home Phone:

Work Phone:

Present Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Permanent Address (If Different from Above):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Are you a United States Citizen or eligible to work in the United States?

Yes
No

Employment Desired:

Regular Full-Time
Temporary/Seasonal

Days and Hours Available to Work:

Driver’s License Number:

State Issued:

Class:

Did you graduate from high school or receive a GED?

Yes
No

How many years of schooling have you completed?

Additional Education Information

High School Name:

High School Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Trade/Business/ Vocational Name:

Trade/Business/Vocational Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Major (If Applicable):

Degree (If Applicable):

Undergraduate Studies Name:

Undergraduate Studies Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Major (If Applicable):

Degree (If Applicable):

Graduate Studies Name:

Graduate Studies Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Major (If Applicable):

Degree (If Applicable):

Apprenticeship Served Name:

Apprenticeship Served Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Major (If Applicable):

Degree (If Applicable):

Please List Relevant Professional Memberships, Registrations, or Licenses:

List Office Machines You Can Operate Efficiently:

List Computer Programs in Which You Are Proficient:

Work History

List complete employment history, beginning with most recent. Include paid and unpaid experience. DO NOT USE “SEE RESUME” OR SIMILAR.

EMPLOYER #1

Employing Firm:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:

Your Title:

Supervisor Name:

First Last

Supervisor’s Title:

Length of Employment:

Start Date:

End Date:

Hours Worked Per Week:

Reason for leaving or seeking other employment:

May we contact this employer?

Yes
No

Principle Responsibilities & % of Time Spent:

List Principle Responsibility and the % of Time Spent for the Responsibility

EMPLOYER #2

Employing Firm:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:

Your Title:

Supervisor Name:

First Last

Supervisor’s Title:

Length of Employment:

Start Date:

End Date:

Hours Worked Per Week:

Reason for leaving or seeking other employment:

May we contact this employer?

Yes
No

Principle Responsibilities & % of Time Spent:

List Principle Responsibility and the % of Time Spent for the Responsibility

EMPLOYER #3

Employing Firm:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:

Your Title:

Supervisor Name:

First Last

Supervisor’s Title:

Length of Employment:

Start Date:

End Date:

Hours Worked Per Week:

Reason for leaving or seeking other employment:

May we contact this employer?

Yes
No

Principle Responsibilities & % of Time Spent:

List Principle Responsibility and the % of Time Spent for the Responsibility

EMPLOYER #4

Employing Firm:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:

Your Title:

Supervisor Name:

First Last

Supervisor’s Title:

Length of Employment:

Start Date:

End Date:

Hours Worked Per Week:

Reason for leaving or seeking other employment:

May we contact this employer?

Yes
No

Principle Responsibilities & % of Time Spent:

List Principle Responsibility and the % of Time Spent for the Responsibility

EMPLOYER #5

Employing Firm:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number:

Your Title:

Supervisor Name:

First Last

Supervisor’s Title:

Length of Employment:

Start Date:

End Date:

Hours Worked Per Week:

Reason for leaving or seeking other employment:

May we contact this employer?

Yes
No

Principle Responsibilities & % of Time Spent:

List Principle Responsibility and the % of Time Spent for the Responsibility

References

List three references you have known at least one year who can attest to your work qualities.

Reference #1

Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship:

Telephone Number:

# Years Acquainted:

Reference #2

Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship:

Telephone Number:

# Years Acquainted:

Reference #3

Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship:

Telephone Number:

# Years Acquainted:

Veteran’s Preference Points

Eligibility & Instructions

Preference points are awarded to qualified veterans and spouses of deceased or disabled veterans to add to their training and experience points. Points are awarded subject to the provisions of Minnesota Statutes §43A.11. To be eligible for veteran’s preference points, you must:

Be separated under honorable conditions from a 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.

The information you provide on this form will be used to determine your eligibility for veteran's preference points. You are required to supply the information, but we cannot award points without it.

Instructions:

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 the FL-802 or death certificate.

If you do not include these documents with this application, be sure to include your name and the name of the position for which you are applying when you do submit the documents. All documents must be received no later than seven (7) calendar days after the application deadline for the position for which you are applying

Veteran:

Self
Spouse

Veteran’s Name:

First Last

Branch of Service:

Date of Active Duty:

Rank at Discharge:

Type of Discharge:

Date of Final Discharge:

Service Number:

Do you have a compensable service-related disability?

Yes
No

Type of Preference Requested:

Veteran
Disabled Veteran
Spouse of Veteran
Spouse of Disabled Veteran

Please upload any supporting documentation:

Max. file size: 50 MB.

AN EQUAL OPPPORTUNITY EMPLOYER, the City of Madelia will hire and promote without regard to such non-job related distinctions such as race, creed, color, age, religion, sex, marital status, status with regard to public assistance, national origin, physical or mental disability, or sexual orientation.

Informed Consent

General Authorization and Release Pursuant to Minnesota Statutes §13.05, Subd. 4, Minnesota Data Practices Act

I hereby authorize and grant my informed consent to permit the release of data to the police department serving the City of Madelia, Minnesota, and/or its agent and/or representatives, data classified as private which concerns me and that may be in your possession. The data which I authorize to be release consists of private data as define by Minnesota Statutes §13.04, Subd. 12, and has been collected by you as a result of my contacts and associations with you and/or your representatives. The information from which release is authorized includes all data which has been collected, created, received, retained, or disseminated in whatever form which in any way relates to my dealings with you or your agency. I understand that the following types of data are among those pertinent to the review of my employment applications: educational records, military record, employment data (current and former), arrest records, conviction records, professional and personal references, and driver’s license records. I understand that the purpose of permitting the City of Madelia to have access to this information is to determine my suitability for employment.

I understand that any decision to hire me is contingent upon the results of an investigatory report. I further understand that misrepresentation or omission of information will be sufficient cause, in and of itself, for rejection or dismissal whenever discovered. I hereby release any person who provides information pursuant to this document from any claims or liability by me or on my behalf.

By signing this authorization, I hereby release the Police Department serving the City of Madelia and the Bureau of Criminal Apprehension from any and all liability which otherwise may or does happen as a result of the release of any and all data, regardless of its accuracy. I also release the City of Madelia from any and all liability for its receipt and use of data received pursuant to their consent.

This authorization or a copy of this authorization shall be valid for a period of one year, but I reserve the right to, at any time prior to the expiration, cancel the written authorization by providing written notice to the City or to you of that fact.

Signature Checkbox:

Checking this box serves as my signature that I have read and agree to the above statements.

Date:

Applicant Information

Name:

First Middle Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Applicant Date of Birth:

Driver’s License Number:

Driver’s License State

CAPTCHA

(507) 642-3245

City of Madelia Application

Additional Education Information

Work History

EMPLOYER #1

EMPLOYER #2

EMPLOYER #3

EMPLOYER #4

EMPLOYER #5

References

Reference #1

Reference #2

Reference #3

Veteran’s Preference Points

Informed Consent

Applicant Information