I. Equal Employment Opportunity

It is the policy of Pope County to provide equal employment opportunity for all, without discrimination, on the basis of race, color, creed, religion, national origin, sex, marital status, status with regard to public assistance, disability, sexual orientation, or age.

II. Data Privacy Notice

The information requested on this application is intended to be used by the County 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 the County being unable or unwilling to offer employment to you. With respect to any special accommodations necessary for completing your application or the interview process, the County may be unable to provide the necessary accommodations if you do not provide the information in Section IV. The information on this application, which is classified as private data under the Minnesota Government Data Practices Act, will not be released outside the County without your consent except as necessary for tax purposes or otherwise required by state or federal law.

III. Position Desired

Title of the Position for which you are applying

Date available to begin employment

How did you hear about us?

IV. Personal Data

Name

First Middle (No initials please) Last

Address

Street Address City State ZIP Code

Phone

Alternate Phone

Email Address

Are you either a U.S. citizen or legally eligible to hold employment in the United States?

Yes

No

Have you previously worked for Pope County?

Yes

No

If yes, position held/department

If yes, under what name may your previous employment records be found?

First Middle Last

Do you have any special needs that may necessitate accommodations in the application interview process?

Yes

No

If yes, please describe the type of accommodation requested

List all other names under which you have been employed or under which your employment or educational records may be found

First

Middle

Last

V. Work/Volunteer Experience

List all work experience, whether or not relevant to this position, and all relevant volunteer experience, most recent listed first.

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Phone Number

Job Title

Job Duties

Start Date

End Date

Reason for Leaving

Add a Second Employer?

Yes

No

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Phone Number

Job Title

Job Duties

Start Date

End Date

Reason for Leaving

Add a Third Employer?

Yes

No

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Phone Number

Job Title

Job Duties

Start Date

End Date

Reason for Leaving

Add a Forth Employer?

Yes

No

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Phone Number

Job Title

Job Duties

Start Date

End Date

Reason for Leaving

VI. Licensure

List current licenses, registrations, or certificates relevant to the position for which you are applying.

List Licenses

License/No.

Issued By

Date

Expiration

Note

All applicable licenses or certifications must be received in the Human Resources 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

Street Address City State / Province / Region ZIP / Postal Code Country

Degree/Diploma Received

Major/Minor

Start Date

End Date

Add a Second School?

Yes

No

Name of School

Address of School

Street Address City State / Province / Region ZIP / Postal Code Country

Degree/Diploma Received

Major/Minor

Start Date

End Date

Add a Third School?

Yes

No

Name of School

Address of School

Street Address City State / Province / Region ZIP / Postal Code Country

Degree/Diploma Received

Major/Minor

Start Date

End Date

Add a Forth School?

Yes

No

Name of School

Address of School

Street Address City State / Province / Region ZIP / Postal Code Country

Degree/Diploma Received

Major/Minor

Start Date

End Date

List/describe any other training and/or experience relevant to the position for which you are applying:

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. The County 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

First Middle Last

Company

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Title

Name of Reference

First Middle Last

Company

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Title

Name of Reference

First Middle Last

Company

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Title

IX. Criminal Background Information

The County 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.

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

Are you the spouse of a deceased honorably discharged veteran or disabled veteran who is unable to work due to such disability?

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.

Note

Proof of applicable military status/eligibility, such as a DD214 form, will be required in order to claim credits. Please attach form DD214 or forward it within five (5) business days. If you receive a passing score, you will be shown your score upon request.

XI. Prior Employment

Have you ever been discharged or forced to resign from prior employment, other than in relation to human rights charge or lawsuit in which you were the claimant/plaintiff?

Yes

No

If yes, identify the employer and describe the circumstances

XII. Personal Statement

Please indicate why you are interested in this position and what you hope to accomplish if selected.

XIII. Certification, Acknowledgment, Authorization and Release

I certify that the answers I have given on this 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 for consideration for employment, and constitutes grounds for my immediate dismissal should I be employed by the County.

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I understand, acknowledge, and agree that no offer of employment is valid or binding until formal approval by the County Board or the appointing authority referenced in the job description and that until such approval the County shall not be liable for any reliance on any oral or written offers of employment made to me.

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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 former employer or volunteer organizations, to release to the County 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 County will use this information in determining my fitness/qualifications for the position I am seeking. This authorization expires one year from the date of my signature below.

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I hereby release the County and all former employers, volunteer organizations and references listed herein and any and all agents acting on behalf of said County, former employers, volunteer organizations, or references, for any and all liability of whatever nature by reason of requesting or providing such information.

Date

Electronic Signature

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Application for Personnel Positions

I. Equal Employment Opportunity

II. Data Privacy Notice

III. Position Desired

IV. Personal Data

V. Work/Volunteer Experience

VI. Licensure

VII. Education

VIII. References

IX. Criminal Background Information

X. Veteran Status

XI. Prior Employment

XII. Personal Statement

XIII. Certification, Acknowledgment, Authorization and Release