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Supervisor’s Name_____________________________ Supervisor’s Title_________________________ Total (Yr/Mo)______________________________ <br />Your Job Title_____________________________________________________________________ ____ Hours Worked Per Week_____________________ <br />Specific Duties_________________________________________________________________________ Last Salary________________________________ <br />_____________________________________________________________________________________ Reason for leaving or seeking other employment <br />______________________________________________________________________________________ _________________________________________ <br />______________________________________________________________________________________ _________________________________________ <br />May we contact this employer? _____Yes _____No If No, please indicate reason_____________________ _________________________________________ <br />______________________________________________________________________________________ _________________________________________ <br />KNOWLEDGE, SKILLS AND ABILITIES SECTION <br />Dictation Experience: <br />Typing Ability: __Yes __No ______WPM Speedwriting Ability: __Yes __No _____ WPM <br />__Yes __No <br />Computer Experience: __Yes __No If Yes, please list computer software programs and hardware you are skilled with. _________________ <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />List other office equipment you can operate.____________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />List any special courses, seminars, workshops and/or training you attended that relate to the job you are applying for.__________________ <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />If relevant, list other registrations, licenses or certificates you have. <br />Type:_________________________________________________________ Date Issued:______________ Date Expires:______________ <br />Type:_________________________________________________________ Date Issued:______________ Date Expires:______________ <br />For Labor & Skilled Trades Only <br />List the equipment you are capable of operating: _________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />This space can be used to add any additional information you deem relevant to better assess your suitability for the position applied for: <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />________________________________________________________________________________________________________________ <br />CONVICTION INFORMATION: <br />No person shall be disqualified from public employment solely or in part because of prior conviction of <br />a crime or crimes, unless the crime or crimes for which convicted directly relate to the position of employment sought. In determining the <br />effect of a conviction, the City shall consider the requirements of Minnesota Statutes, Chapter 364. Applicants who are finalists for certain <br />positions will be subject to a criminal background investigation. <br />Have you ever been convicted as an adult for a criminal violation? ___ Yes ___No If yes, please complete the following for each offense. <br />Nature of OffenseDate of Offense and Location Disposition <br />Nature of OffenseDate of Offense and Location Disposition <br /> <br />