East Central Solid Waste Commission Employment Application

NAME:________________________________________________

SOCIAL SECURITY NUMBER:________________________

PRESENT ADDRESS:____________________________________________________________________________

(House or Box No.) (Street) (City) (State) (Zip Code)

PERMANENT ADDRESS:____________________________________________________________________________

(House or Box No.) (Street) (City) (State) (Zip Code)

TELEPHONE NUMBER:_________________________________

OTHER TELEPHONE NUMBER:_____________________________

POSITION APPLYING FOR:________________________________________________________________

DATE AVAILABLE TO START EMPLOYMENT:______________________________________________

INDICATE YOUR PREFERENCE: [ ] FULL TIME [ ] OVERTIME (if applies)

[ ] PART TIME [ ] WEEKENDS (if applies)

IF AVAILABLE FOR PART TIME, LIST DAYS & HOURS:_____________________________________________________________

ARE YOU AT LEAST 18 YEARS OF AGE? [ ] YES [ ] NO

EDUCATION:

ARE YOU A HIGH SCHOOL GRADUATE? [ ] YES [ ] NO GED?______________________________

OTHER SCHOOLS ATTENDED Location DEGREE/DIPLOMA/

(OTHER THAN HIGH SCHOOL) (City & State) MAJOR/MINOR GPA CERTIFICATION_______

1.____________________________________________________________________________________

2.____________________________________________________________________________________

3.____________________________________________________________________________________

MILITARY SERVICE RECORD:

WERE YOU IN THE U.S. ARMED FORCES? [ ] YES [ ] NO BRANCH_______________

RANK AT DISCHARGE:__________________________________________________________________________

NOTE: To claim Veterans Preference, you must provide a copy of your DD Form 214. Also, to claim Disabled Veterans

Preference, you must provide a letter from the VA indicating your percentage of service connected disability. Your failure to

provide this information may result in your not being qualified to receive Veterans Preference points.

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OTHER TRAINING RECEIVED (I.E. SPECIAL COURSES, ON THE JOB TRAINING, ARMED FORCES TRAINING, ETC.

______________________________________________________________________________________

___________________________________________________________________________________________________________

PLEASE DESCRIBE OTHER SKILLS, EXPERIENCES, OR INTERESTS YOU POSSESS THAT MAY BE USEFUL IN EVALUATING

YOUR FOR EMPLOYMENT: (INCLUDES VOLUNTEER WORK).

______________________________________________________________________________________

WORK EXPERIENCE: (LIST ALL POSITIONS HELD, START WITH PRESENT. USE ADDITIONAL SHEETS IF NECESSARY)

________________________________________ ___________________________________

Employer Telephone #

_____________________________________________________ From__________________ To ____________________

Address

_____________________________________________________ _______________________________________________

Job Title Name of Supervisor

Describe Job Duties:

______________________________________________________________________________________

Reason for Leaving:______________________________________________________________________________

________________________________________ ___________________________________

Employer Telephone #

_____________________________________________________ From__________________ To ____________________

Address

_____________________________________________________ _______________________________________________

Job Title Name of Supervisor

Describe Job Duties:

______________________________________________________________________________________

________________________________________________________________________________________________________

Reason for Leaving:______________________________________________________________________________

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MAY WE CONTACT THE EMPLOYERS LISTED ABOVE UNLESS YOU INDICATED THOSE YOU DO NOT WANT US TO

CONTACT?

DO NOT CONTACT:_______________________________________ REASON:__________________________________________

PERSONAL REFERENCES:

(Please do not list relatives or former employers)

NAME ADDRESS OCCUPATION YEARS ACQUAINTED

1.__________________________________________________________________________________________________________________________________________________________________________

2,__________________________________________________________________________________________________________________________________________________________________________

3. ____________________________________________________________________________________________________________________________________________________________________________

PERMISSION IS HEREBY GIVEN TO ECSWC TO INVESTIGATE PREVIOUS EMPLOYMENT, EDUCATIONAL BACKGROUND, AND REFERENCES. I CERTIFY THAT ANSWSERS GIVEN HEREIN ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. IN THE EVENT OF EMPLOYMENT, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION GIVEN IN MY APPLICATION OR INTERVIEW (S) MAY RESULT IN DISCHARGE. I UNDERSTAND THAT I AM REQUIRED TO

ABIDE BY ALL RULES AND REGULATIONS OF ECSWC.

______________________________________________ __________________________________________________

Date Signature of Applicant

TENNESSEN WARNING

(TO BE COMPLETED BY APPLI CANT AS THEY APPLY FOR POSITIONS WITH THE COUNTY)

In accordance with the Minnesota Government Data Practices Act, ECSWC is required to inform you of your rights as they pertain to the private information collected from you. Private data is that information which is available to you, not the public. The personal information we collect about you is private.

The information collected from your or from other agencies or individuals authorized by you is used to determine your qualifications for East Central Solid Waste Commission Openings.

You are not required to provide this information; however, it is necessary to determine if you qualify for employment. Disclosure of your social security number is voluntary unless you are hired. If hired, you must disclose it in order to be in compliance with state and federal tax withholding laws. If you do not supply the required information, ECSWC will not be able to consider you for

employment. The use of the private data we collect is limited to that necessary for the administration and management of the county hiring process. Persons or agencies with whom this information may be shared include:

1. Heads of department where job openings occur

2. Supervisors in departments where job openings occur

3. County Personnel

4. Payroll Clerk/Department

Unless otherwise authorized by state statute or federal law, other government agencies utilizing the reported private data must also

treat the information as private.

You may wish to exercise your rights as contained in the Minnesota Government Data Practices Act. These include:

1. The right to see and obtain copies of the data maintained on you.

2. Be told the contents and meaning of the data.

3. Contest the accuracy and completeness of the data.

To exercise these rights, contact: Isanti County Coordinator/Personnel Officer.

I have read and understand the above information regarding my rights as a subject of government data.

_______________________________________ ________________________________________________________________

Date Signature