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City of Mounds View • <br /> page4 <br /> PERSONAL REFERENCES(do not include relatives) <br /> Name I Occupation I Years Aquatinted <br /> I Day Phone Number <br /> (V11 lot. . 'p=)c -7? %C (.-J <br /> � SI cJ <br /> e.vAdis- •Jo4n),rcAl rm--' i2.1 I sc7 - j7 26,S1 <br /> Please list any relatives currently employed with the City of Mounds View <br /> Name /L)c' Relationship <br /> Name Relationship <br /> CONVICTION INFORMATION The information requested below relates to criminal convictions. Before any <br /> applicant is rejected on the basis of criminal conviction,he/she will be notified in writing and will be given any rights to processing of <br /> complaints or grievances afforded by Minnesota Statute 364. Applications who are finalists will be subject to a criminal background <br /> investigation. <br /> Have you ever been convicted as an adult of a felony, gross misdemeanor, or misdemeanor for which a jail <br /> sentence of more than 90 days could have been imposed?_ Yes )( No <br /> If yes, dates and places <br /> MILITARY- Complete this section only if you served in the armed forces <br /> Branch of Service Length of time served: Type of ischarge: <br /> Describe your duties and any special training <br /> Please refer to Page 5 of employment application for further instructions regarding military information. <br /> I hereby certify that all answers to the above questions are true and I agree and understand any false information contained in this <br /> appiication may cause rejection of this application or termination of employment. I understand all of the information on this <br /> application is subject to verification. I authorize schools. former and current employers,and references listed above to provide my <br /> record,reason for Leaving, and ail other information they may have concerning me and I release all parties from any and all liability <br /> and claims for damage whatsoever that may result therefrom. <br /> I understand that to qualify for regular employment.I must submit and pass a physical examination by a City designated doctor. I also <br /> agree that in the event I am employed by the City, I will submit to further physical examinations when requested by the City. <br /> I do not know of any reason why I woifid not be able to perform the duties and tasks of this position as outlined in the job description. <br /> . <br /> /// G 'i 7) <br /> APPLICANTS SIGNATURE A✓c./-'� �' <br /> <. ( = / yc DATE / C -`7 5 <br /> • <br /> • <br />