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City of Orono Employment Application

2. 

3. Application for Employment
   City of Orono<br>P.O.Box<br>Crystal Bay, MN 55323<br>(952) 249-4600

   City of Orono
   P.O.Box
   Crystal Bay, MN 55323
   (952) 249-4600

5. Title of Specific Position for Which You Applying

6. Date of Application
   Date of Application

7. Date Available for Work
   Date Available for Work

9. Contact Information:

11. First Name

12. Last Name

14. Address

16. City

17. State

18. Zip Code

20. Phone Number

21. Email Address

23. County of Residence

24. Are you 18 years of age or over?*

    1. Yes
    2. No

25. If not, state Date of Birth

27. Have you previously been employed by the City?

    1. Yes
    2. No

28. If yes, date
    If yes, date

29. Previous Position with the City of Orono

31. Driver's License Number

32. Driver's License Class

33. Driver's License State

35. Education:

37. Did you graduate from high school or receive a GED?*

    1. Yes
    2. No

38. School Attended

39. How many years of education have you had *
    -- Select One --7891011121314151617181920

41. Name and Location of College, University, Technical School

42. Did You Graduate?

    1. Yes
    2. No

43. Degree, Certificate - Course of Study

45. Name and Location of College, University, Technical School

46. Did You Graduate?

    1. Yes
    2. No

47. Degree, Certificate - Course of Study

49. Name and Location of College, University, Technical School

50. Did You Graduate?

    1. Yes
    2. No

51. Degree, Certificate - Course of Study

53. Work Experience (Experience and training ratings are determined by this information. Please be complete.) List your present or most recent experience first. Attach additional sheets if necessary.

55. Employing Firm

56. Phone Number

58. Address

60. City

61. State

62. Zip Code

64. Your Title

65. Supervisor

    Supervisor's Title

67. Number and Type of Positions You Supervised

69. Principal Responsibilities

71. Length of Employment
    Length of Employment Start Date

    —

    Length of Employment End Date

72. Hours Per Week

73. Last Salary

75. May we contact your present employer?

    1. Yes
    2. No

76. If No, Please explain

78. Reason for Leaving

80. Employing Firm

81. Phone Number

83. Address

85. City

86. State

87. Zip Code

89. Your Title

90. Supervisor

    Supervisor's Title

92. Number and Type of Positions You Supervised

94. Principal Responsibilities

96. Length of Employment
    Length of Employment Start Date

    —

    Length of Employment End Date

97. Hours Per Week

98. Last Salary

100. May we contact your present employer?

     1. Yes
     2. No

101. If No, Please explain

103. Reason for Leaving

105. Employing Firm

106. Phone Number

108. Address

110. City

111. State

112. Zip Code

114. Your Title

115. Supervisor

     Supervisor's Title

117. Number and Type of Positions You Supervised

119. Principal Responsibilities

121. Length of Employment
     Length of Employment Start Date

     —

     Length of Employment End Date

122. Hours Per Week

123. Last Salary

125. May we contact your present employer?

     1. Yes
     2. No

126. If No, Please explain

128. Reason for Leaving

130. Employing Firm

131. Phone Number

133. Address

135. City

136. State

137. Zip Code

139. Your Title

140. Supervisor

     Supervisor's Title

142. Number and Type of Positions You Supervised

144. Principal Responsibilities

146. Length of Employment
     Length of Employment Start Date

     —

     Length of Employment End Date

147. Hours Per Week

148. Last Salary

150. May we contact your present employer?

     1. Yes
     2. No

151. If No, Please explain

153. Reason for Leaving

155. The City of Orono will not discriminate against or harass any employee or applicant for employment because of race, color, creed, religion, national origin, sex, disability, marital status, or status with regard to public assistance.

157. List any relevant current professional memberships, registrations or licenses. Include date first issued.

159. Job Relevant Volunteer and Unpaid Work Experience

161. Kind of Volunteer Activity

162. No. Hrs Per Mo.

163. Dates
     Dates Start Date

     —

     Dates End Date

165. Major Responsibilities

167. Kind of Volunteer Activity

168. No. Hrs Per Mo.

169. Dates
     Dates Start Date

     —

     Dates End Date

171. Major Responsibilities

173. Kind of Volunteer Activity

174. No. Hrs Per Mo.

175. Dates
     Dates Start Date

     —

     Dates End Date

177. Major Responsibilities

179. Describe any additional experience or training that qualifies you for this job.

181. Additional Attachments

     Please attach additional documents such as work history, resume, etc. if applicable.

183. In accordance with the Immigration Reform and Control Act of 1986, the City of Orono hires only U.S. Citizens and lawfully authorized alien workers. If hired, you will be required to provide written documentation of citizenship or legalized alien program. Failure to provide said documentation will result in dismissal.

185. MN Stat. Sec. 518.611, Subd. 8, requires employers to obtain information from all new employees regarding court-ordered child support obligations that are required by law to be withheld from income. Failure to provide said documentation will result in dismissal.

187. Have you served a sentence in jail or prison or been convicted of a misdemeanor or felony for which a jail sentence could have been imposed?

     1. Yes
     2. No

188. You may answer "No" if the conviction or criminal records have been annulled, sealed, set aside, or purged, or if you have been pardoned pursuant to the law.

     1. Yes
     2. No

190. Yes If "Yes", please specify.

192. If you are hired for this position you may be required to undergo a physical examination at the City's expense to determine whether or not you are able to perform the duties of this position in an effective and safe manner, and whether or not accommodations need to be made for you.

194. The City of Orono does not discriminate on the basis of handicapped status in the admission or access to, or treatment or employment in, its programs or activities. It is the policy of the City of Orono to provide reasonable accommodations to the known physical and mental limitations of qualified handicapped applicants and employees in order for them to perform the essential functions of the job in question.

196. Did you serve in the military service of this country and separate under honorable conditions from any branch of the armed forces of the U.S. after having served on active duty for 181 consecutive days or by reason of disability incurred while serving on active duty?

     1. Yes
     2. No

198. If "Yes", indicate dates of military service.
     If "Yes", indicate dates of military service. Start Date

     —

     If "Yes", indicate dates of military service. End Date

199. If "Yes", are you a permanent resident of the State of Minnesota?

     1. Yes
     2. No

201. Describe your duties and any special training.

203. Give the names of three people outside of relatives who can be contacted regarding your qualifications, work habits, and character.

205. First Name

206. Last Name

208. Phone Number

209. Position and relation to your work

211. First Name

212. Last Name

214. Phone Number

215. Position and relation to your work

217. First Name

218. Last Name

220. Phone Number

221. Position and relation to your work

223. The City of Orono is an EQUAL OPPORTUNITY EMPLOYER

225. The City of Orono has the right to verify information provided in the application. False information may subject an applicant to the penalty provisions of M.S. 43A.39.

227. In connection with this application for employment, I authorize the City of Orono and any agent acting on its behalf to conduct an inquiry into any job-related information contained in this application, including, but not limited to, my records maintained by an educational institution related to academic performance such as transcripts. Moreover, I hereby release the City of Orono and any agent acting on its behalf from any and all liability of whatsoever nature by reason of requesting such information from any person.

     1. Yes
     2. Yes, but not present employer until job is offered.
     3. No (We may be unable to hire you without this information.

229. Electronic Signature Agreement

     I declare that any statement in this application or information provided is true and complete and hereby acknowledge that I have read and understand the information below.

     1. I agree.
231. Electronic Signature

232. Date
     Date

234. IMPORTANT FACTS ABOUT INFORMATION ON YOUR APPLICATION This application is to assist in the process of referring you for possible employment. Certain information requested on the application is private, that is, may be released only to you or to agencies where you may be considered for employment (to comply with M.S. 15.165, Subd. 2). If you are employed, the data will be available to the Department of Finance, the Internal Revenue Service, and the Social Security Administration for payroll and tax purposes. If you disagree with the data we have about you, you may notify the City.

236. Private Data

237. Why we Ask for it

238. Are You Legally Obligated to Provide it?

239. What May Happen if you Don't Provide it?

241. Social Security Number

242. To distinguish you from all other applicants, and to make processing more efficient.

243. No

244. In most cases, nothing. However, it will help to ensure that we do not confuse your records with those of others.

246. Date of Birth (Final applicants only)

247. To conduct check of criminal record for certain positions

248. No

249. Failure to provide information may be cause for rejecting an applicant.

251. Name (The names of finalists for a position are public information.)

252. To distinguish you from all other applicants.

253. Yes

254. Failure to provide information may be cause for rejecting an applicant.

256. Street Address (City and County of residence are public information.)

257. To be able to contact you to determine availability for interview.

258. No

259. We may not be able to employ you in certain jobs where you may be required to come to work on short notice.

261. Sex, Racial/Ethnic Group, Handicapped Status, Veteran Status

262. To be able to make Equal Opportunity reports as required by law.

263. No

264. We will not be able to determine whether our selection processes result in discrimination, or to take affirmative action in our hiring.

266. Conviction Record

267. To determine whether we may legally accept an application from you and determine whether your record may be a job-related consideration.

268. Yes

269. We will not be able to make determinations required by law.

271. All other information on the application is public, and may be given to anyone for any purpose.

Leave This Blank:


273. 1. Receive an email copy of this form.
274. Email address

     This field is not part of the form submission.

275. Submit

* indicates a required field