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Martin Soil and Water Conservation District |
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923 North State Street, Suite 110 |
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Fairmont, MN 56031 |
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(507) 235-6680 |
APPLICATION FOR CLASSIFIED PERSONNEL POSITIONS
| I. EQUAL EMPLOYMENT OPPORTUNITY: It is the policy of Martin SWCD to provide equal employment opportunity for all, without discrimination on the basis of race, color, creed, religion, national origin, sex, marital status with regard to public assistance, disability, sexual orientation, or age. | |||
| I. DATA PRIVACY NOTICE: The information requested on this application is intended to be used by Martin SWCD in determining suitability for employment for the position which you are currently seeking or may seek in the future. You are not legally required to provide any of the information on this form at this time. However, failure to provide complete, accurate information may result in Martin SWCD being unable or unwilling to offer employment to you. With respect to any special accommodation necessary to completing your application or the interview process, Martin SWCD may be unable to provide the necessary accommodations if you do not provide the information in Section IV. The information on this application with is classified as private data under the Minnesota Government Data Practices Act will not be released outside Martin County without your consent except as necessary for tax purposes or as otherwise required by state or federal law. | |||
| III. POSITION DESIRED Title of position for which your are applying: ________________________________________ Date available to Begin Employment:__________________________________________
If part time, indicate maximum hours available per week ___________________________ |
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| IV. PERSONAL DATA Name: _________________________________________________________ Last First Middle |
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Address:___________________________________________________________________________________ Street City State Zip Phone:________________________________________ Cell Phone: __________________________________ |
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| Are you either a U.S. citizen or legally eligible to hold employment
in the United States? Yes_______ No________ Have you previously worked for the District? Yes_______ No________ If yes, position held/department: If yes, under what name(s) may your previous employment records be found?____________________________________ |
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| Do you have any special needs with may necessitate accommodations in
the application/interview process? Yes_______ No________ If yes, please describe the type of accommodation requested: ___________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________ |
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| List all other names under which you have been employed or under
which employment or educational records may be found. _____________________________________________________________________________________________ |
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| V. WORK/VOLUNTEER EXPERIENCE List all work experience, whether or not relevant to this position, and all relevant volunteer experience, most recent to be listed first. Employer Name: ________________________________________________________________________________ Employer Address: _______________________________________________________________________________ Job Title: _______________________________________________________________________________________ Job Duties: _____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Dates mm/dd/yyyy of Employment/Experience: __________________________________________________________ Reason for leaving: _______________________________________________________________________________ |
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| Employer Name:
________________________________________________________________________________ Employer Address: _______________________________________________________________________________ Job Title: _______________________________________________________________________________________ Job Duties: _____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Dates mm/dd/yyyy of Employment/Experience: __________________________________________________________ Reason for leaving: _______________________________________________________________________________ |
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| Employer Name:
________________________________________________________________________________ Employer Address: _______________________________________________________________________________ Job Title: _______________________________________________________________________________________ Job Duties: _____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Dates mm/dd/yyyy of Employment/Experience: __________________________________________________________ Reason for leaving: _______________________________________________________________________________ |
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| Employer Name:
________________________________________________________________________________ Employer Address: _______________________________________________________________________________ Job Title: _______________________________________________________________________________________ Job Duties: _____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Dates mm/dd/yyyy of Employment/Experience: __________________________________________________________ Reason for leaving: _______________________________________________________________________________ |
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| Employer Name:
________________________________________________________________________________ Employer Address: _______________________________________________________________________________ Job Title: _______________________________________________________________________________________ Job Duties: _____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Dates mm/dd/yyyy of Employment/Experience: __________________________________________________________ Reason for leaving: _______________________________________________________________________________ |
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| Employer Name:
________________________________________________________________________________ Employer Address: _______________________________________________________________________________ Job Title: _______________________________________________________________________________________ Job Duties: _____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Dates mm/dd/yyyy of Employment/Experience: __________________________________________________________ Reason for leaving: _______________________________________________________________________________ Attach additional sheets if necessary. |
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| VI. LICENSURE List current licenses, registrations, or certificates relevant to the position for which you are applying. License/No. Issued By Date Expiration ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
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| All applicable licenses or certifications must be received in the Personnel Office prior to employment commencing. If hired, you remain responsible for ensuring that all applicable licenses remain in effect. | |||
| VII. EDUCATION Include high school and/or institution issuing GED and any additional education/courses taken. Do not list dates of attendance for high school. List most recent first. Name of School:_________________________________________________________________________________ Address of School:_______________________________________________________________________________ Degree/diploma Received:__________________________________________________________________________ Major/Minor:____________________________________________________________________________________ Dates mm/dd/yyyy of Attendance: ___________________________________________________________________ |
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| Name of
School:_________________________________________________________________________________ Address of School:_______________________________________________________________________________ Degree/diploma Received:__________________________________________________________________________ Major/Minor:____________________________________________________________________________________ Dates mm/dd/yyyy of Attendance: ___________________________________________________________________ |
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| Name of
School:_________________________________________________________________________________ Address of School:_______________________________________________________________________________ Degree/diploma Received:__________________________________________________________________________ Major/Minor:____________________________________________________________________________________ Dates mm/dd/yyyy of Attendance: ___________________________________________________________________ |
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| Name of
School:_________________________________________________________________________________ Address of School:_______________________________________________________________________________ Degree/diploma Received:__________________________________________________________________________ Major/Minor:____________________________________________________________________________________ Dates mm/dd/yyyy of Attendance: ___________________________________________________________________ |
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| List/describe any other training and/or experience relevant to the
position for which you are applying: __________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ |
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| VIII. REFERENCES: These should be people in a
position to discuss your qualifications for the position you seek.
Include especially managers, directors, or heads of departments under
whom you have worked. Indicate any who are related to you.
Martin SWCD reserves the right to contact all prior employers,
educational institutions or institutions where you have volunteered in
addition to references listed below.
Name of Reference: ______________________________________________________________________________ Address: _______________________________________________________________________________________ Phone Number: __________________________________ Title: ___________________________________________ |
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| Name of Reference:
______________________________________________________________________________ Address: _______________________________________________________________________________________ Phone Number: __________________________________ Title: ___________________________________________ |
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| Name of Reference:
______________________________________________________________________________ Address: _______________________________________________________________________________________ Phone Number: __________________________________ Title: ___________________________________________ |
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| IX. CRIMINAL BACKGROUND INFORMATION__________________________________________________ The District will request information regarding criminal history in the event that you become a finalist for the position which you are applying. For certain positions, criminal background information will be requested during the application stage. Further, the District may conduct a criminal background check on individuals upon making a contingent job offer. Please refer to the job description for this position to determine if such a check will be conducted. If the job description states that a criminal check will be conducted, no offer of employment shall become final until receipt of the results of the criminal background check from the BCA, the content of which is acceptable to the District, and formal approval by the appointing authority. |
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| X. VETERAN STATUS Are you an honorably discharged Veteran of the Armed Forces of the United States or are you otherwise eligible to claim Veteran's Preference Points? Yes________ No__________ Do you wish to claim Veteran's Preference points? Yes________ No__________ If you are a disabled Veteran and wish to claim additional points, please check here.________ |
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| Proof of applicable military status/eligibility, such as a DD214 form, will be required in order to claim credits. Please attach DD214 form or forward it within five (5) business days. | |||
| XI. PRIOR EMPLOYMENT Have you ever been discharged or forced to resign from prior employment, other than in relation to a human rights charge or lawsuit in which you were the claimant/plaintiff? Yes____ No____ If so, identify the employer and describe the circumstances: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ |
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| XII. PERSONAL STATEMENT Please indicate why you are interested in the position and what you hope to accomplish if selected.____________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ |
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| XIII. UNEXCUSED ABSENCES FROM WORK How many days were you inexcusably absent from work during the preceding three (3) years other than absences due to illness or injury of you or your immediate family? _________________ |
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| XIV. CERTIFICATION, ACKNOWLEDGMENT AND RELEASE I certify that the answers I have given on the application are true and correct to the best of my knowledge. I understand that any false or misleading information provided, or any omission or concealment of facts, will disqualify me from consideration for employment, and constitutes grounds for my immediate dismissal should I be employed by the District. I understand, acknowledge and agree that no offer of employment is valid or binding until formal approval by the District Board or the appointing authority referenced in the job description and that until such approval that the District shall not be liable for any reliance on any oral or written offers of employment made to me. In connection with this application I hereby authorize any and all current and former employers, organizations where I have volunteered ("volunteer organizations") and references named in this application, or any agent of such a former employer or volunteer organizations, to release to the District and its agents any and all information regarding my job performance and fitness/qualifications to perform the position I am presently seeking and any other employment or related information, both public and private, in their possession. I understand that the District will use this information to determine my fitness/qualifications for the position I am seeking. This authorization expires one year from the date of my signature, below. I hereby release the District and all former employers, volunteer organizations and references listed herein and any and all agents acting on behalf of said District, former employers, volunteer organizations or references, for any and all liability of whatever nature by reason of requesting or providing such information. Date _________________________________ Signature _________________________________________________ (DO NOT PRINT) |
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CONSENT FOR RELEASE OF EMPLOYMENT AND APPLICANT RECORDS AND RELEASE OF LIABILITY I, _______________________________________ hereby consent to the release of any and all personnel data or other information about me or related to me or my employment or application for employment with the Martin Soil & Water Conservation District, Fairmont, Minnesota, including but not limited to: resumes, applications, interview notes, correspondence, and any and all other information related to my employment, application for employment or other attempt(s) to secure employment, including performance evaluations, disciplinary records, investigative data or notes whether or not said investigation resulted in disciplinary action, and all other information contained in my personnel file or otherwise maintained in any form by previous employers whether or not previously reviewed by me, to: Martin Soil & Water Conservation District. This information is needed for the purpose of determining by qualifications and fitness for employment. I was employed by __________________________________ from _______________ to _______________ or applied for employment on or about ________________________. Records may be found under the following additional names; _________________________________________________________________. In connection with this authorization for release of information, I hereby release the Martin Soil & Water Conservation District of Fairmont, Minnesota and all of its current and former employees, officers, Council members, agents or representatives from any and all manner of liability of whatever nature by reason of requesting or providing such information. I understand that this authorization shall continue in full force and effect unless specific written revocation is sent to the Personnel Department of the Martin Soil & Water Conservation District by certified mail. Date: ____________________________________ _____________________________________________________ Signature |