Martin Soil and Water Conservation District

We welcome you as an applicant for employment.  It is our policy to provide equal opportunity employment.  This policy prohibits discrimination on the basis of race, color, religion, sex, national origin, physical handicap, or age. This policy applies to full, part-time, temporary, and seasonal employment.

If part time, indicate maximum hours available per week ___________________________

On what date would you be available for employment?  _____________________, 20______________

PERSONAL INFORMATION

NAME ________________________________________________________________________________

                                  Last                                                                 First                                                           Middle

ADDRESS ____________________________________________________________________________                                          No.                                Street                            City                              State                           Zip

HOME TELEPHONE (           )                                     OFFICE TELEPHONE (           )_________________

Are you under 18 years of age?         YES           NO              Are you older than 70?         YES           NO   

Are you legally eligible for employment in the U.S.?       YES        NO (Verification may be required)

If the position you are applying for requires driving, give your driver’s license number.

No. _______-_________-_________-_________-_________         Class         A           B           C           D 

Are there any necessary accommodations needed for you to fulfill the job descriptions:  _________________________________________________________________________________________

EDUCATION

High School _______________________________________________________________________________

College/University ____________________________________________________________________________

Other _____________________________________________________________________________________

SKILLS AND QUALIFICATIONS

Include any job related license or certification requirements, training courses, job related skills (computer software/hardware, tools, machinery, typing), honors, awards, or special accomplishments (leadership activities, public speaking, performance awards): 

PERSONAL REFERENCES

Name                                           

EMPLOYMENT HISTORY

Begin with most recent position.  Include volunteer experience which relates to the job for which you are applying.  Military training may be included.

DATES OF

NAME AND ADDRESS

JOB TITLE, DUTIES,

SUPERVISOR

REASON FOR

EMPLOYMENT

OF PREVIOUS EMPLOYER

RESPONSIBILITIES

NAME & PHONE

LEAVING

FROM

TO

PHONE

FROM

TO

PHONE

FROM

TO

PHONE

FROM

TO

PHONE

FROM

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PHONE

Are there any employers you do not wish us to contact?          YES                 NO

CRIMINAL BACKGROUND INFORMATION

criminal conviction may prohibit you from working in certain positions.

If yes, give date, place, charge and circumstances:  ___________________________________________________________________________________________

INFORMATION DISCLOSURE NOTICE TO APPLICANTS

In accordance with Minn. Stat. Chapter 13, we must inform you of your rights as a subject of government data.  The information you give us about yourself is needed to identify you and assist in determining your suitability for the position for which you are applying.  The information that we collect about you is classified as either Public or Private. Public means that it is available to anyone who asks to see it. Private means that the information is available only to the person the information is about and to the staff who must  use it in the normal course of conducting District business and as otherwise provided for by law.  Data considered public: veteran status, relevant test scores, rank on eligible list, job history, education and training, and work availability. Your name is considered private until you are certified as eligible for appointment to a vacancy or considered as a finalist. All other information on the application is private.  Answers to the questions of name, address, and conviction record are legally obligated. Failure to provide information may cause rejecting an application. Providing other private data is not legally obligated; however, not providing the information may impede the hiring process.  All job offers are contingent on District Board approval.

A. Have you used another name while employed (Other than name used on the application)? yes no If yes, please indicate:_________________________________________________________________________________________

I certify that the information contained in this application is true and complete.  I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired.  I authorize the verification of any or all information listed above.