High School:	Select: GED or Diploma
College/Vocation:	Degree:

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:

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:

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 City or myself may terminate the employment relationship that may result from my application at any time.

I understand and agree to terms listed above	Date:

**Please fill out Background Investigation form, Addendum and Veteran's Preference form. You must also sign and date your application for employment.
You must also sign and date your application for employment

 

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

PLEASE INSERT THIS PAGE INTO THE COMPLETED APPLICATION FORM AND RETURN TO THE CITY HUMAN RESOURCES OFFICE.

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.