<p> City of Beaver Bay Employment Application NOTICE TO APPLICANTS</p><p>Instructions for completing the application: 1. Fill out a separate application for each job you are applying for. 2. Read the job announcement carefully to be sure you meet all the minimum qualifications. 3. Your application must be received in the office of the City Clerk/Treasurer no later than 4:00 p.m. on the LAST DAY FOR FILING as stated in the job announcement or be post-marked on or before that date. 4. If you require an accommodation to participate in the application process, please contact the City Clerk/Treasurer. (Example: Hearing impairment requiring written rather than oral instructions.) 5. All materials submitted in support of your application become the property of the City of Beaver Bay and cannot be returned. Work samples, letters of recommendation, etc. should not be submitted with your application. 6. Veterans’ Preference: Qualified veterans and disabled veterans and spouses of deceased or disabled veterans may apply to have extra points credited to their examination scores. However, you must pass the examination and you must submit a photocopy of your DD214 Form and/or other proof of applicable military status/eligibility for this preference to be applied. If you would like to request this preference or if you have any questions about this preference, please contact the City Clerk/Treasurer.</p><p>TENNESSEN WARNING</p><p>Important notice concerning information provided on your application:</p><p>The Minnesota Government Data Practices Act requires that you be informed that the following information, which you will be asked to provide in the application process, is considered private data:</p><p> Home address  Home phone number  Social Security number  Date of birth  Conviction record  Sex  Age  Racial/ethnic group  Disability type</p><p>Page 1 of 5 City of Beaver Bay Employment Application Your name is private data unless or until you are certified as eligible for appointment to a vacancy or you become a finalist for a position.</p><p>We ask for this information for the following reasons:</p><p> To distinguish you from all other applicants and identify you in our personnel files.  To enable us to verify that you are the individual who takes the examination.  To enable us to contact you when additional information is required, send you notices, and/or schedule you for interviews.  To determine if you meet the minimum age requirements (if any).  To determine whether or not your conviction record may be a job-related consideration affecting your suitability for the position you applied for.  To enable us to ensure your rights to equal employment opportunities.  To meet federal reporting requirements.  To make application processing more efficient.</p><p>The data supplied may be used for other lawful purposes. </p><p>Furnishing Social Security number, date of birth (unless a minimum age is required), sex, age, racial/ethnic group, and disability data is voluntary, but refusal to supply other requested information will mean that your application may not be considered.</p><p>Private data is available only to you and to other persons in the City or City-related programs who have a bona fide need for the data. Public data is available to anyone requesting it and consists of all data furnished in the employment process which is not designated in this notice as private data.</p><p>If you are hired by the City, you will be legally required to supply your Social Security number and all applicable tax information. This information will be sent to federal and state tax authorities and to the Social Security Administration, and will enable us to compute your salary deductions. Insurance data, which you will be required to furnish in order to participate in City insurance plans, will be classified as private, as will payroll deduction data. </p><p>Page 2 of 5 City of Beaver Bay Employment Application</p><p>CITY OF BEAVER BAY Employment Application – If Available, Please Attach Résumé</p><p>It is the policy of the City of Beaver Bay to provide equal employment opportunities without regard to race, color, creed, national origin, religion, sex, age, sexual orientation, marital status, familial status, veteran status, status with regard to public assistance, membership or activity in a local commission, genetic information, disability, or any other classification protected under law, to all qualified applicants and employees in all aspects of the employment relationship, including but not limited to recruitment, employment, job assignment, training, promotion, transfers, termination, rate of pay and other forms of compensation and benefits.</p><p>Please omit references to any organizations or activities that would reveal information about any of these protected classifications.</p><p>APPLICANT INFORMATION</p><p>Last Name First M.I. Date</p><p>Street Address Apartment/Unit #</p><p>City State ZIP</p><p>Phone</p><p>Date Available Desired Salary</p><p>Position Applied for</p><p>Are you legally authorized to work in the YES NO U.S.? Have you ever worked for the City? YES NO If so, when?</p><p>After hire, will you be able to provide proof YES NO of age?</p><p>EDUCATION</p><p>High School Address</p><p>Years completed Did you graduate? YES NO Degree</p><p>College Address</p><p>Years completed Did you graduate? YES NO Degree</p><p>Other Address</p><p>Years completed Did you graduate? YES NO Degree</p><p>REFERENCES Please list three professional references.</p><p>Full Name Relationship</p><p>Company Phone ( )</p><p>Address</p><p>Full Name Relationship</p><p>Company Phone ( )</p><p>Address</p><p>Full Name Relationship</p><p>Company Phone ( )</p><p>Page 3 of 5 City of Beaver Bay Employment Application</p><p>Address</p><p>PREVIOUS EMPLOYMENT</p><p>Company Phone ( )</p><p>Address Supervisor</p><p>Job Title Starting Salary $ Ending Salary $</p><p>Responsibilities</p><p>Length of Employment Reason for Leaving</p><p>May we contact your previous supervisor for a reference? YES NO </p><p>Company Phone ( )</p><p>Address Supervisor</p><p>Job Title Starting Salary $ Ending Salary $</p><p>Responsibilities</p><p>Length of Employment Reason for Leaving</p><p>May we contact your previous supervisor for a reference? YES NO </p><p>Company Phone ( )</p><p>Address Supervisor</p><p>Job Title Starting Salary $ Ending Salary $</p><p>Responsibilities</p><p>Length of Employment Reason for Leaving</p><p>May we contact your previous supervisor for a reference? YES NO </p><p>MILITARY SERVICE</p><p>Branch Length of Service</p><p>Rank at Discharge Type of Discharge</p><p>Page 4 of 5 City of Beaver Bay Employment Application</p><p>DISCLAIMER AND SIGNATURE Please read the following statements. If they are accurate, please sign this application form. Applications which are not signed will not be considered as properly completed. I certify that all of the information given on this application form is true, complete and correct to the best of my knowledge. By signing this form, I am acknowledging that any false or misleading information supplied by me shall be grounds for not hiring me. I am also acknowledging that any false or misleading information supplied by me shall be grounds for automatic termination of employment, should this fact be discovered after I have been hired. I authorize the City of Beaver Bay to investigate all statements and information included on this application, including but not limited to my employment record. I release the City of Beaver Bay and all educational institutions, employers and personal references I have listed herein, and their employees, officers and agents, from any and all liability for all claims or damages of any kind in connection with the release of information about me to the City of Beaver Bay pursuant to this authorization, and do hereby further agree to defend, indemnify and hold harmless the City of Beaver Bay, educational institutions, employers and personal references from and against any and all such claims, actions, causes of actions, suits, losses, liabilities, damages and expenses (including attorneys’ fees, costs, and disbursements). I understand that this application is not a contract of employment. I understand and acknowledge that any employment relationship with the City of Beaver Bay is of an “at will” nature, which means that the employee may resign at any time and the City of Beaver Bay may terminate the employee at any time, with or without cause or notice. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the City of Beaver Bay. </p><p>Signature Date</p><p>Page 5 of 5</p>