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City of Kalispell 201 1st Ave E. P.O. Box 1997 Kalispell, Montana 59903-1997 (406) 758-7757 Fax (406) 758-7758 The information contained on this form is sought in good faith. It will not be used in any way to discriminate against any applicant for employment in violation of state and federal law. Under state and federal law, qualified applicants with disabilities are entitled to reasonable accommodations. Modifications or adjustments may be provided to assist applicants to compete in the recruitment and selection process, to perform the essential duties of the job or to enjoy equal benefits and privileges of employment available to other employees. An applicant must request an accommodation when needed. The essential job duties are included in the vacancy announcement. Employment Preference: The Veterans Employment Preference Act and the Handicapped Persons Employment Preference Act provide preference in public employment for certain military veterans and people with disabilities or their eligible relatives. An applicant claiming employment preference must complete an Employment Preference Form, available through your local Montana Job Service. The applicant must check that they're requesting a preference as defined and attach the necessary documentation. For more information, contact your local Job Service. I am requesting an Employment Preference as defined above and attached the appropriate documentation. NOTE: The City of Kalispell requires pre-employment & random drug &/or alcohol screening for positions that are considered “Safety Sensitive” or where a Commercial Driver’s License “CDL” is required. PLEASE PRINT OR TYPE and FILL OUT APPLICATION COMPLETELY AND SIGN. (Unsigned or incomplete applications will not be accepted!). Position(s) Applied For: Date of Application: Date Position Closes: Last Name: First Name: M.I. Phone Numbers (Include Area Code): Home: Work: Cell: Address: City State Zip Code Email Address: If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No N/A Are you a relative of a city employee, mayor or council? Yes No If yes, what relationship? Are you currently employed? Yes No May we contact your present employer? Yes No On what date would you be available for work? Are you available to work:: Full time Part time Seasonal Temporary Have you been convicted of a felony within the last 7 years? Yes No (Conviction(s) will not necessary disqualify an applicant from employment.) If answer is yes, please explain: My signature below certifies that all information on this and all attached pages is true, correct and complete to the best of my knowledge and contains no willful falsifications or misrepresentations. Falsifications or misrepresentations may disqualify me from consideration for employment with the City of Kalispell or, if hired, may be grounds for termination at a later date. I also understand that extensive background checks may be required and employers may be contacted as references. Date ---PAGE BREAK--- 2 EDUCATION: You may respond to this section on a separate sheet of paper if all relevant blocks are completed and the same format is followed. On each sheet, write your name and job title for which you are applying. High School Name & Address: Received Diploma or Equivalency Certificate? Yes No If “No”, enter highest grade completed: Dates Credits Received Date of College or University Name & Location Attended Earned (BA, MA, ETC.) Degree Major Field Other Schools or Training Courses Dates Did you (Which help you qualify) Name & Location Attended complete? Title Description of Course Total Hours PROFESSIONAL LICENSES, REGISTRATION & CERTIFICATIONS Engineering, Medical, CPA, ICBO, ICC, CDL, etc.) Licensing Agency Name & Location Type of License Endorsement / Restriction (If Applicable) Date Licensed Date Expires SPECIAL SKILLS: List those skills that you possess which may help in the job you’re applying for. (Typing, Computer Software Programs, Mechanical, etc.) EQUIPMENT: List those types of equipment you can operate and specify name or model you have used that may help in the job you’re applying. computers, copy machines, forklift, chainsaw, dump truck, grader, etc.). ---PAGE BREAK--- 3 EXPERIENCE: Begin with your present or most recent job and if applicable; list your work experience for the last fifteen (15) years along with last salary with emphasis on experience that is relevant to the position for which you are applying. Include military service and any volunteer work experience that would help you qualify. List each promotion as a separate position. You may respond to this section on a separate sheet of paper if all questions in the blocks are answered and the same format is followed. On each sheet write your name and job title for which you are applying. Notice to applicants: Information that you provide on this application is subject to verification and extensive background checks may be undertaken. Previous employers may be contacted as references. Do you want to be informed before we contact your present employer? Yes No Name & complete address of employer: Job Title: Type of Business: Immediate Supervisor(s): Dates of Employment (From – To) Phone Number: Average Hours Per Week: Total Time Employed (Note Years / Months): Full or Part Time Describe your duties in detail (knowledge, skills, abilities, employees supervised, and accomplishments). Reason for leaving: Last salary or hourly wage rate: Name & complete address of employer: Job Title: Type of Business: Immediate Supervisor(s): Dates of Employment (From – To) Phone Number: Average Hours Per Week: Total Time Employed (Note Years / Months): Full or Part Time Describe your duties in detail (knowledge, skills, abilities, employees supervised, and accomplishments). Reason for leaving: Last salary or hourly wage rate: ---PAGE BREAK--- 4 Name & complete address of employer: Job Title: Type of Business: Immediate Supervisor(s): Dates of Employment (From – To) Phone Number: Average Hours Per Week: Total Time Employed (Note Years / Months): Full or Part Time Describe your duties in detail (knowledge, skills, abilities, employees supervised, and accomplishments). Reason for leaving: Last salary or hourly wage rate: PERSONAL & PROFESSIONAL REFERENCES: Relationship Name: Address (City, State, Zip): Phone: Personal I Professional Have you ever worked for or applied for a position with the City of Kalispell? Yes No If yes, please explain and give dates and position(s) applied or worked: If applying for a specific position, how did you hear about it? City Website/Internet: Local newspaper: Job Service: In-person: Friend/Relative: Other: NOTE: NORMALLY, DUE TO HIGH VOLUMES OF APPLICATIONS, ONLY THOSE CANDIDATES SELECTED FOR INTERVIEWS WILL BE NOTIFIED. Mail, hand deliver, fax or email completed application to: City of Kalispell Attn: Human Resource Director 201 1st Avenue East PO Box 1997 Kalispell, MT 59903-1997 Fax (406) 758-7758 Email: [EMAIL REDACTED] Revised 10/24/2013 ---PAGE BREAK--- City of Kalispell 201 1st Ave E. P.O. Box 1997 Kalispell, Montana 59903-1997 (406) 758-7700 Fax (406) 758-7758 EEOC VOLUNTARY SELF-IDENTIFICATION The Montana Human Rights Act requires the City of Kalispell to make and keep records relevant to the determinations of whether unlawful employment practices have been or are being committed. This Survey will be separated from your Application. The survey information will be kept confidential, used only for statistical reports and other lawful purposes. The information you and others provide will be used to monitor the City's recruitment and selection practices. This form is optional: failure to complete this form will have no impact on any employment decision. Date: Job applied for: Name: Mailing Address: City/State/Zip: Phone (Please check your appropriate gender, ethnic group, veteran or disability) GENDER: Male Female RACE/ETHNICITY: Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races. VETERAN STATUS (Check any that apply): Disabled Veteran Other Protected Veteran Three – Year Recently Separated Veteran (Enter Discharge/Release Date): Armed Forces Service Medal Veteran DISABILITY: A “disabled individual” means any person who has a physical or mental impairment which substantially limits one or more of such person’s major life activities, has a record of such impairment, or is regarded as having such impairment. ( Check yes, if applicable): YES, I have as disability as defined above. REFERRAL SOURCE: – How did you first learn of this position? Newspaper ad Job Service office/website City of Kalispell website College ad Career/Job Fair Referral from someone Other Please return this form to City of Kalispell Human Resources Department. 201 1st Ave E. P.O. Box 1997 Kalispell, Montana 59903-1997 ---PAGE BREAK--- PD-25A (rev. 10-01-03) EMPLOYMENT PREFERENCE FORM Name Position Applied For Job Title Position No. Department Name To claim preference under the Veterans' Public Employment Preference Act or the Persons with Disabilities Public Employment Preference Act, complete the following. Providing the following information is voluntary but must be included with the application in order to claim employment preference. This information will be kept confidential and will only be used during the hiring process to apply employment preference. Applicants hired by the state will have this information placed in a separate confidential selection file. Contact your local Job Service for details on veterans’ preference. Contact your local Montana Vocational Rehabilitation Services Office, Department of Public Health and Human Services (PHHS) for details on obtaining persons with disabilities preference certification. 1. To claim Veterans' Employment Preference you must be a U.S. Citizen and (check one of the boxes below): A Veteran, if 1. you have been separated under honorable conditions, AND have served more than 180 consecutive days of active federal military duty other than for training in the Army, Air Force, Navy, Marines, or Coast Guard or were a member of the reserves who served on federal military duty during a period of war or in a campaign or expedition for which a campaign badge is authorized. 2. You are or have been a member of the Montana Army or Air National Guard who has satisfactorily completed a minimum of 6 years service in armed forces, the last 3 of which have been served in the Montana Army or Air National Guard. A Disabled Veteran, if 1. you have been separated under honorable conditions from military duty, AND 2. you have an established Armed Forces service-connected disability OR are receiving compensation, disability retirement benefits, or pension from the U.S. Department of Veterans Affairs or military department, OR you have received a Purple Heart. The spouse of a disabled veteran if the veteran's disability prevents him/her from working. The unremarried surviving spouse of a veteran or disabled veteran. The mother of a veteran, if 1. THE VETERAN died under honorable conditions while serving in the Armed Forces, OR THE VETERAN has a service-connected, permanent, and total disability, AND 2. YOUR SPOUSE is totally and permanently disabled, OR YOU are the unremarried widow of the father of the veteran. 2. To claim Montana Persons with Disabilities Employment Preference you must be (check one of the boxes below): A person with a disability certified by PHHS, OR The spouse of a totally (100%) disabled person certified by PHHS AND have resided continuously in Montana for at least 1 year immediately before applying for employment. 3. In the box below, check the attachment you have included to document your eligibility for employment preference. DD-214 showing the character of discharge Service-connected disability letter PHHS Disability Certification A document issued by the Office of the Adjutant General of the Montana National Guard certifying service. SIGNATURE (typed or written): DATE SIGNED: On-line form available at http://www.discoveringmontana.com/statejobs/employpref.asp