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MILITARY SERVICE: Branch of Service: Period of Active Duty: From ______________ To _____________ Rank at Discharge: Type of Discharge: _________________________________________ Date of Final Discharge: Describe your duties and any special training: VETERAN’S PREFERENCE POINTS: Preference points are awarded to qualified veterans and spouses of deceased veterans to add to their application results. Points are awarded subject to the provisions of Minnesota Statute 43A.11. To be eligible for veteran’s preference points you must: (1) Be separated under honorable conditions from any branch of the armed forces of the U.S. after having served on active duty for 181 consecutive days or by reason of disability rated at 50% or more, incurred while serving on active duty, and be a citizen of the U.S. or resident alien; or be the surviving spouse of a AND NOT deceased veteran or the spouse of a disabled veteran who because of the disability is not able to qualify; 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 applying for preference points must supply their marriage certificate, the Veteran DD214 and FL- 802 or death certificate. ARE YOU APPLYING FOR VETERAN’S PREFERENCE POINTS? ___YES ___NO If yes, your DD214 or other supporting documentation must be received no later than five (5) calendar days after the application deadline. PREFERENCE REQUESTED : ___Veteran (5pts) ___Disabled Veteran (10pts) ___Spouse of Disabled or ___Deceased Veteran (5pts) Are you receiving or eligible for a military pension? ___Yes ___No Do you have a service-related disability? ___Yes ___No (_______%) REFERENCES : Please list 3 references (not relatives), who have known you for at least one (1) year, who can attest to your work qualities. NameRelationship to YouOccupationTelephone Number NOTICE TO APPLICANT: Information requested on your application that is defined by Minnesota Statute as public may be released on request and other information defined by Minnesota Statute as private may be released only to you or to governmental entities authorized access by law. NAME/SOCIAL SECURITY NUMBER (SSN): Used to identify you in relation to other applicants. You are legally required to provide your name, but not your SSN. Failure to provide this information may result in a delay in processing or rejection of your application. LICENSE INFORMATION: Used to certify applicants for positions where State law requires appropriate license. You are legally required to provide this information. Failure to provide this information may result in rejection of your application. CITIZENSHIP STATUS: Used to certify applicants for work in the U.S. as determined by laws of the U.S. Department of Labor and the State of Minnesota. Failure to provide this information may result in rejection of your application. Minnesota Statute Section 518.6111, requires employers to obtain information from all new employees regarding court-ordered child support obligations that are required by law to be withheld from income. If hired, you will be required to provide such documentation. Failure to provide said documentation will result in dismissal. In accordance with the Immigration Reform and Control Act of 1986, the City of Centerville hires only U.S. citizens and lawfully authorized alien workers. If hired, you will be required to provide written documentation of citizenship or legalized alien program. Failure to provide said documentation will result in dismissal. If you are hired for this position, you may be required to undergo a physical examination at the employer's expense to determine whether or not you are able toperform the duties of this position in an effective and safe manner, and whether or not accommodations are necessary for you.