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1 Employment of Relatives List any relatives currently employed by the City of Arden Hills Name Relationship To You l Personal References Not former employees or relatives) Name and Occupation Address Phone Number Tennesseen Warning/Data Practices Notice to All Applicants The Minnesota Government Data Practices Act requires that you be informed of the purposes and intended uses of the information you provided to the City of Arden Hills during the application process or during employment. Any information about yourself that you provide will be used to identify you as an applicant and to assess your qualifications for employment with the City. if you wish to be considered for employment, you are required to provide the information requested in the Application for Employment. If you refuse to supply information requested by the City,it may mean your application will not be considered. You are hereby advised that, under Minnesota law,the following information given by an applicant is considered to beup blic: veteran status, relevant test scores,rank on our eligible list;job history;education and training;work availability. As an applicant, your name is consideredrip vate until you are certified as eligible for appointment to a position or when applicants are considered by the appointing authority to be finalists for a position with the City of Arden Hills. "Finalist"means an individual who is selected to be interviewed by the appointing authority prior to selection. The data concerning you,which is placed in your application folder or in your personnel file and which is not listed as public,is private. This private date will be shared with you and those members of the City staff who need it to process the application,update your personnel record, evaluate your work performance and if you are handicapped,provide the necessary accommodations. It may also be shared with the following: persons authorized to have access to the information under State or Federal law; persons authorized by Court Order to have access to the information;and persons to whom you consent in writing to have access to the information. With the exception of racial and ethnic data, the data you give us about yourself is needed to identify you and to assist determining your suitability for the position for which you are applying. Racial and ethnic data used in summary form by the City's Affirmative Action Program to monitor protected class employment and to meet Federal, State, and Local reporting requirements. Furnishing racial and ethnic data about yourself,as well as your social security number,is voluntary. I certify that answers herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this Application for Employment as may be necessary in arriving at an employment decision. I understand that this application is not,and is not intended,to be a contract for employment. 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 also,that I am required to abide by all rules and regulations of the City. I certify that I have read the"Notice to Application"regarding the Minnesota Data Practices Ace(MN Statutes 1301-1390), and I understand my rights as a subject of date. Applicant Signature: Date: Dave Perrault 1/05/2015 City of Arden Hills* 1245 West Highway 96, Arden Hills, MN 55112 *(651)792-7800