RETURN TO:
ASSISTANT TO THE CITY MANAGER
CITY OF COLUMBIA HEIGHTS
590 40TH AVENUE NE
COLUMBIA HEIGHTS, MN 55421
DATE RECEIVED BY CITY
CITY OF COLUMBIA HEIGHTS
EMPLOYMENT APPLICATION
We welcome you as an applicant for employment. Your application will be considered in competition with others for the
position in which you are interested. Please furnish complete information as outlined in this application. Submission of an
incomplete application may disqualify you from consideration for employment. All information contained in or connected
with this application will be considered for use only in conjunction with your possible employment with the City of Columbia
Heights. You are encouraged to attach any additional information which you believe qualifies you for the position for which
you are applying. It is the policy of the City of Columbia Heights to provide equality of opportunity in employment to all
persons. The City of Columbia Heights does not discriminate on the basis of race, color, religion, national origin, political
affiliation, marital status, disability, sex or age (except when sex or age is a bona fide occupational qualification) in all
aspects of its personnel policies, programs, practices, operations, and provision of services. Please print in ink or type.
PERSONAL INFORMATION
ARE YOU UNDER 18? YES NO IF YES. DATE OF BIRTH:
ARE YOU WILLING TO WORK OVERTIME IF NECESSARY? YES NO
ARE YOU A UNITED STATES CITIZEN OR IF NOT, DO YOU HAVE PERMISSION TO WORK IN THIS COUNTRY? YES NO
EDUCATION AND TRAINING
DIPLOMA, DEGREE OR
~)CATE EARNED
QTR./SEM.
CREDIT TOTAL TYPE OF SCHOO~ NAME AND ADDRE$S OF SCHOOL MAJOR & MINOR SUBJEC~
EDUCATION AND TRAINING CONTINUED
LIST ANY CORRESPONDENCE COURSES, SPECIAL COURSES, SEMINARS, WORKSHOPS, AND TRAINING PROGRAMS YOU ATTENDED THAT MIGHT
RELATE TO THIS POSITION. PLEASE REVIEW THE JOB POSTING BEFORE RESPONDING.
COURSE TITLE OFFERED BY LENGTH OF PROGRAM TOTAL CLASSROOM HOURS
EMPLOYMENT HISTORY
INSTRUCTIONS: BEGINNING WITH YOUR PRESENT OR MOST RECENT EMPLOYMENT OR OCCUPATION, LIST ALL YOUR EMPLOYERS FOR AT LEAST THE LAST
FIVE YEARS. IT IS IMPORTANT TO PROVIDE COMPLETE INFORMATION. RESUMES AND ADDITIONAL MATERIALS MAY BE SUBMITTED IN SUPPORT OF, BUT NOT
IN LIEU OF, THE FOLLOWING.
PRESENT OR LAST EMPLOYER ADDRESS CITY STATE ZIP CODE
SUPERVISOR'S NAME AND TITLE PHONE NO. ( MA Y WE CONT ACT ?
YES
IFN6f:WHY?
NO
DATES EMPLOYED (MO/YR)
FROM TO
HOURS WORKED PER WEEK JOB TITLE
REASON FOR LEAVING
LAST SALARY
PRINCIPAL DUTIES AND RESPONSIBILITIES. PERCENTAGE OF TIME SPENT IN EACH AREA OF RESPONSIBILITY
1. %
2.
%
3.
%
4.
%
5. %
SECOND LAST EMPLOYER ADDRESS CITY STATE ZIP CODE
SUPERVISOR'S NAME AND TITLE PHONE NO. ( MAY WE CONTACT ?
YES
IF N"6T;-WHY?
NO
DATES EMPLOYED (MO/YR)
FROM TO
HOURS WORKED PER WEEK JOB TITL~
REASON FOR LEAVING LAST SALARY
PRINCIPAL DUTIES AND RESPONSIBILITIES: PERCENTAGE OF TIME SPENT IN EACH AREA OF RESPONSIBILITY
1. %
2.
%
3.
%
4.
%
5.
%
2
EMPLOYMENT HISTORY CONTINUED
THIRD LAST EMPLOYER ADDRESS CITY STATE ZIP CODE
SUPERVISOR'S NAME AND TITLE PHONE NO. ( MAY WE CONTACT ?
YES
IF "NOT;- WHY?
NO
DATES EMPLOYED (MONR)
FROM TO
HOURS WORKED PER WEEK JOB TITLE
REASON FOR LEAVING
LAST SALARY
PRINCIPAL DUTIES ~$PONSIBlLITIES: PERCENTAGE OF TIME SPENT IN EACH AREA OF RESPONSIBILITY
%
2
%
3
%
4.
%
5.
%
FOURTH LAST EMPLOYER ADDRESS CITY STATE ZIP CODE
SUPERVISOR'S NAME AND TITLE PHONE NO. MA Y WE CONT ACT ?
YES
IFN6T:WHY?
NO
HOURS WORKED PER WEEK JOB TITLE DATES EMPLOYED (MO/YR)
FROM TO
REASON FOR LEAVING LAST SALARY
PRINCIPAL DUTIES AND RESPONSIBILITIES: PERCENTAGE OF TIME SPENT IN EACH AREA OF RESPONSIBlLI
1. %
2. %
3. %
4.
%
5. %
OFFICE EQUIPMENT/COMPUTER SOFTWARE PROGRAMS
WHAT OFFICE MACHINES DO YOU OPERATE PROFICIENTLY?
DICTATION 10-KEY CALCULATOR SWITCHBOARDfTELEPHONE CONSOLE PAPER COPIER FAX MACHINE
DO YOU HAVE EXPERIENCE WITH WORD PROCESSING/DATA ENTRY? YES NO
TYPE OF COMPUTER: IBM OR COMPATIBLE APPLE/MACINTOSH OTHER,SPECIFY'
LIST COMPUTER SOFTWARE YOU USE PROFICIENTLY
TYPEWRITER TYPING SPEED
WORDS PER MINUTE"
MINUTE
WORD PROCESSOR TYPING SPEED
WORDS PER MINUTE.
SHORTHAND SPEED
WORDS PER MINUTE
CALCULATOR SPEED
KEYSTROKES PER
DATE LAST TESTED DATE LAST TESTED DATE LAST TESTED DATE LAST TESTED
OTHER LICENSES
SUPERVISION
REFERENCES PLEASE GIVE THE NAMES OF TWO PERSONS (NOT RELATED TO YOU\ ~N TESTIFY TO YOUR CHARACTER AND QUALIFICATIONS
CONVICTION INFORMATION
NO PERSON SHALL BE DISQUALIFIED FROM PUBLIC EMPLOYMENT SOLELY OR IN PART BECAUSE OF PRIOR CONVICTION OF A CRIME OR CRIMES, UNLESS THE CRIME OR
CRIMES FOR WHICH CONVICTED DIRECTLY RELATE TO THE POSITION OF EMPLOYMENT SOUGHT, IN DETERMINING IF A CONVICTION DIRECTLY RELATES TO THE POSITION
OF PUBLIC EMPLOYMENT SOUGHT, THE HIRING AUTHORITY SHALL CONSIDER THE REQUIREMENTS OF MINNESOTA STATUTES, CHAPTER 364, FINAL APPLICANTS MAY BE
SUBJECT TO A CRIMINAL BACKGROUND INVESTIGATION.
HAVE YOU EVER BEEN CONVICTED AS AN ADULT OF A FELONY, GROSS MISDEMEANOR, OR MISDEMEANOR FOR WHICH AJAIL SENTENCE CAN BE
I IMPOSED?
YES NO
4
VETERAN'S PREFERENCE POINTS APPLICATION INSTRUCTIONS
Preference points are awarded to qualified veterans and spouses of deceased or disabled veterans.
Points are awarded subject to the provisions of Minnesota Statutes 43A.11. To be eligible for veterans
preference points, you must:
1. Be separated under honorable conditions from any branch of the armed forces of the United States
after having served on active duty for 181 consecutive days or by reason of disability incurred while
serving on active duty, and be a citizen of the United States or resident alien; or be the surviving
spouse of a deceased veteran (as defined above) or the spouse of a disable veteran who because
of the disability is not able to qualify; AND
2. Not be currently receiving or eligible to receive a monthly veteran's pension based exclusively on
length of military service.
The information you provide on this form will be used to determine your eligibility for veteran's
preference points. You are not required to supply this information, but we cannot award veteran's
points without it.
YOU MUST SUPPLY A COPY OF YOUR DD214. DISABLED VETERANS MUST ALSO SUPPLY
FORM FL-802 OR AN EQUIVALENT LETTER FROM A SERVICE RETIREMENT BOARD.
SPOUSES APPL YING FOR PREFERENCE POINTS MUST SUPPL Y THEIR MARRIAGE cERTIFICATE,
THE VETERAN'S DD214 AND FL-802 OR DEATH CERTIFICATE.
If you supply the supporting documentation by separate majl, your name and the position applied for
must be included.
VETERAN'S PREFERENCE POINTS APPLICATION
Veteran
Self
Spouse
If spouse, veteran's name
Branch of Service Period of Active Duty
From: To
Rank at Discharge Type of Discharge Date of Final Discharge Service No
Do you have a compensable service-related
disability?
Yes No
Preference Requested Veteran
Disabled Vet
eran
Spouse of Disabled Veteran
Spouse of Deceased Veteran
IMPORTANT NOTICE TO ALL APPLICANTS
Minnesota law requires that you be informed of the purposes and intended uses of the information you provide
to the City of Columbia Heights during the application process or during employment.
Any information about yourself that you provide to the City of Columbia Heights during the application and
interview process will be used to identify you as an applicant and to assess your qualifications for employment
with the City. Although you are not legally required to supply information, you are required to provide the
information requested in the Employment Application, if you wish to be considered for employment. If you do
not supply the information requested, it may mean that your application will not be considered.
The information may be provided to:
1) Persons authorized under state or federal law; and
2) Persons authorized by court order; and
3) Persons to whom you consent in writing; and
4) All individuals in the City who are authorized.
I authorize and consent to having City representatives make inquiries about the content of this application if
am to be considered for employment.
Former employers are authorized to give information about me in any form, oral or written. They are hereby
released from all liability for issuing such information. I hereby knowingly waive any privileges, including
protection under the Data Practices Act, that I have as to such information.
I understand that misrepresentation or omission of facts will be cause for cancellation of consideration for
employment or dismissal if employed.
I understand that appointment to a full-time or part-time position is, at minimum, conditional upon a satisfactory
check of references, satisfactory completion of a physical examination and satisfactory completion of a drug and
alcohol test. A copy of the City's Drug and Alcohol Testing Policy is available upon request from the Assistant
to the City Manager. I agree to complete these tests if I receive a conditional offer of employment.
My signature confirms that I have read and understand the authorization and notice to applicants set forth
above. I recognize that my failure to sign, accurately complete or falsify information in this application will
automatically disqualify me from consideration for employment.
Applicant's Signature
Date
0596 6
Please see other side and return this sheet with application.
CITY OF COLUMBIA HEIGHTS
The following requested confidential information will not affect you as an applicant. The voluntary
information that you provide will be used to find out how effective our recruitment efforts are in
reaching all segments of the population and in validation of our selection and placement methods.
The information will not be maintained in personnel files and it will not be made available to any
person involved in decisions affecting an individual's appointment or promotion to a position. We
would appreciate your cooperation in our efforts to ensure Affirmative Action and Equal
Employment Opportunity.
Date:
Position for which you are applying 2
3. Name:
4 Sex: Male Female
With which racial/ethnic group do you identify yourself?
following.
Please check only ~ of the
Black
-Hispanic
American Indian or Alaskan Native
Asian or Pacific Islander
White
Do you have a disability?
If yes, please explain:
Yes No 6
Please 7 The following information will assist us in surveying our recruitment program
cooperate by checking the appropriate line. How did you hear about the job opening?
-City of Columbia Heights Administrative Offices
--Current City of Columbia Heights Employee
-Cable Television -Government Access Channel
-Minnesota State Employment Agency
-College, Technical or High School
-Minority Group Referral Source; specify: ---
-Newspaper; specify:
-Women's Referral Source; specify: -
-Bulletin Board Postings; specify:
-Handicapped Referral Source; specify
-Other; specify:
0596
NOTICE TO APPLICANT
The Minnesota Government Data Practices Act (Minnesota Statutes 13.01
sections that affect applicants seeking employment with the City of Columbia Heights.
13.88) has two
First, when you are asked to provide personal data, the City must advise you of:
.The purpose and intended use of the data;
.Whether you may refuse or are legally required to supply the requested data;
.Any known consequences arising from your supplying or refusing to supply the data; and
.The identity of other persons or organizations authorized by the State or Federal law to
receive the data you provide.
Second, the following information you provide for employment is automatically public'
.Your veteran's status;
.Your job history;
.Your education and training;
.Your relevant test scores;
.Your rank on our eligibility list; and
.Work availability.
As an applicant, your name is considered private until you are certified as eligible for appointment
to a position or are considered by the appointing authority to be a finalist for a position in public
employment.
If you are hired, the following additional data about you will be public:
.Your name;
.Your city and county of residence;
.Your actual gross salary, salary range, and actual gross pension;
.The value and nature of employer paid benefits, including the basis for and the amount of any
added remuneration to your salary;
.Your job title and job description;
.The dates of your first and last employment with us;
.The existence and status of any written complaints or charges against you while you work for
the City of Columbia Heights, whether or not they resulted in disciplinary action;
.The final disposition of any disciplinary action together with the specific reasons for action;
.Your work location and work telephone number;
.Your education and training background;
.Honors and awards you have received;
.Time sheets or other comparable data that are only used to account for your work time for
payroll purposes; and
.Your previous work experience.
All data concerning you which is placed in your personnel files and which is not listed above is
private data. This private data will be available to you and to those members of City staff needing
it to process City records. In addition, the following persons or organizations are authorized by
State and Federal Law to receive this data if they so request:
.The Bureau of Census
.Federal, State, and County Auditors
.The State Department of Public Welfare
.The Department of Human Rights
.Federal officials investigating compliance with Affirmative Action and Equal Employment
Opportunity requirement
.Labor Organizations and the Bureau of Mediation Services
.Data may also be made available through court order.
With the exception of demographic data, the data you provide is needed to identify you and to
assist in determining your suitability for the position for which you are applying. Racial and ethnic
data are used in summary form by the City's Affirmative Action Program to monitor protected class
employment and meet federal, state, and local reporting requirements. Furnishing racial and
ethnic data about yourself is voluntary .
