218 North Meridian Street Phone: 952-873-5553

P.O. Box 129 Fax: 952-873-5509

Belle Plaine, MN 56011

Website: belleplainemn.gov

APPLICATION FOR FIRE DEPARTMENT EMPLOYMENT

We welcome you as an applicant for employment with the City of Belle Plaine. It is the City of Belle Plaine’s policy
to provide equal opportunity in employment. The City of Belle Plaine will not discriminate on the basis of race, age,
religion, national origin, or any other basis protected by law.
The information contained in this application is considered private data under the Minnesota Data Practices Act,
and will be used only in conjunction with your possible employment. Please furnish complete information, so we
may accurately and completely assess your qualifications. You may attach any other information which provides
additional detail about your qualifications for employment in the position you seek. Your application will be
evaluated in comparison to the requirements for that position. As an applicant for employment, your name is
considered private until you become a finalist for employment with the City of Belle Plaine. You are considered a
finalist if and when you are selected for a final interview.

Title of position applied for: Volunteer Firefighter

Hours available : _____________________________________________________________________________

Personal Information
Name: _____________________________________________________________________________________
First Middle Last

Street address: _____________________________________________________________________

City, State, Zip: _____________________________________________________________________

Home phone: _____________________________ Cell phone:_______________________________

Work or other phone: ________________________________________________________________

Email ____________________________________________________________________________
Are you legally eligible to work in the United States in the position for which you are applying?

____ Yes ____ No (proof of citizenship or work eligibility will be required as a condition of employment)

Are you at least 18 years old? ___Yes ____ No

Education Information
Circle the highest grade completed:

1 2 3 4 5 6 7 8 9 10 11 12/GED 13 14 15 16 MA MS PHD JD
grade school high school college/technical graduate

NAME/ADDRESS OF SCHOOL DEGREE EARNED/COURSE OF STUDY

High School:

College:

Graduate School:

Technical/Vocational:

Other:

List any other courses, seminars, workshops, or training you have which may provide you with skills related to the
position applied for: __________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Note: If the position you are applying for requires a college degree or other academic credential, the City may
require a certified transcript from the educational institution that granted you that credential.

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 Employment Experience
List present or most recent employer first.

Employer Name: ______________________________ Supervisor Name: _________________________

Employer Address: _______________________________________________________________________

Employer Telephone: ______________________________

Dates of Employment: From ____________ To_____________ Number of Years ________

Job Title: ____________________________________

Describe your job duties and responsibilities: __________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Why did you leave? _____________________________________________________

May we contact your present employer? ___ yes ___ no

_______________________________________________

Next most recent employer:

Employer Name: ______________________________ Supervisor Name: _________________________

Employer Address: _______________________________________________________________________

Employer Telephone: ______________________________

Dates of Employment: From ____________ To_____________ Number of Years ________

Job Title: ____________________________________

Describe your job duties and responsibilities: __________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Why did you leave? _____________________________________________________

May we contact your present employer? ___ yes ___ no

_______________________________________________

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PLEASE LIST ANY LICENSES, REGISTRATIONS, OR CERTIFICATIONS RELEVANT TO THE POSITION FOR
WHICH YOU ARE APPLYING:

__________________________________________________________________________________
LICENSE/REGISTRATION/CERTIFICATE ISSUED BY NO. EXPIRATION

IF THE POSITION YOU ARE APPLYING FOR INVOLVES DRIVING:

VALID DRIVERS LICENSE STATE LICENSE NO. CLASS EXPIRATION

YES NO ISSUED

HAVE YOU HAD ANY MOVING VIOLATIONS IN THE LAST FIVE (5) YEARS?
YES NO IF YES, PLEASE EXPLAIN.

Unsalaried Experience
Describe any unsalaried or volunteer experience relevant to the position for which you are applying (you may
exclude, if you wish, information which may reveal race, sex, religion, age, disability, or any other protected status).

Military Experience
Did you serve in the U.S. Armed Forces or are you serving in the U.S. Armed Forces? ___ yes ___ no

Describe your duties: _______________________________________________________________________

_________________________________________________________________________________________

Do you wish to apply for Veteran’s Preference Points? ____ yes ____ no

If you answered “yes” to the above question, you must complete the enclosed application for Veteran’s
Preference Points, and submit the application and required documentation to the City of Belle Plaine within seven
days of the application deadline for the position for which you are applying.

Authorization
I certify that all information I have provided in this application for employment with the City of Belle Plaine is true
and complete to the best of my knowledge. I agree and understand that any false statements or omission of
information contained in this application or any supplemental materials I submit may disqualify me from further
consideration for employment or result in immediate dismissal if discovered at a later date.

I acknowledge that I have received a copy of the job description and/or summary for the position(s) for which I am
applying. I further acknowledge my understanding that employment with the City of Belle Plaine is “at will” and
that employment may be terminated by either the City of Belle Plaine or myself at any time, with or without notice.

_________________________________________ _________________________
Signature Date

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 Application for Veteran’s Preference Points

Eligibility: Preference points are awarded to qualified Veteran’s and spouses of deceased or disabled veterans to
add to their training and experience examination results. Points are awarded subject to the provisions of
Minnesota Statues 43A.11. To be eligible for veteran’s preference points, you must:

1. Be separated under honorable conditions from any branch of the United States armed forces after
having served on active duty for 181 consecutive days or by reason of disability incurred while serving on
active duty, and be a citizen of the United States or resident alien; or be the surviving spouse of a
deceased veteran (as defined above) or the spouse of a disabled veteran who because of the disability is
not able to qualify;
and

2. NOT 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.

Instructions: 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, and the Veteran’s DD214 and FL-802 or death certificate.

If you do not include these documents with this application, be sure to include your name, and the name of the
position for which you are applying, when you do not submit the documents.

All documentation must be received no later than seven (7) calendar days after the application deadline for the
position for which you are applying.

Veteran’s Preference Application

Veteran: ____self ____spouse If spouse, Veteran’s Name: ____________________

Branch of Service: __________________ Dates of active duty: from _______ to ________

Rank at Discharge: __________________ Type of Discharge: _________________________

Date of final Discharge: _______________ Service Number: ________________________

Are you receiving or eligible for a military pension? ____ yes ____no

Do you have a comprehensive service-related disability? ____ yes ____no

Preference type requested:

___ veteran ____ disabled veteran ____ spouse of veteran ____ spouse of disabled veteran

Supporting documentation: __attached __will submit within seven days of application deadline.

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 CITY OF BELLE PLAINE
INFORMED CONSENT/RELEASE OF INFORMATION

I hereby authorize The Minnesota Bureau of Criminal Apprehension to disclose all criminal history record information to the
City Administrator of the City of Belle Plaine, or designee to inspect and gather information retained by local, county, state, and
federal agencies.

The following named individual has made application with the City of Belle Plaine for the position of

_________________________________.

____________________________________________________________________________________
(Name: First, Middle, Last)

____________________________________________________________________________________
(Maiden, Alias or Former Name)

___________________________________ ________________________________
(Date of Birth) (Sex)

___________________________________ ________________________________
(Social Security Number - Optional) (Driver’s License Number)

I realize that I am not legally required to sign this form, however, if I choose not to, the City of Belle Plaine will not be able to
determine whether my conviction record, if any, is a job related consideration. In the event the City of Belle Plaine determines
that my conviction record is a job related consideration, I will be notified in writing and will be given any rights to processing of
complaints or grievances afforded by Minnesota Statute, Chapter 364. I understand that information disclosed to the City of
Belle Plaine may be released only pursuant to the statutory provisions of Minnesota Statute, Chapter 13.

I authorize references and current and/or former employers, if so noted on application, to release data, including performance
evaluations and complaints against me, to the City of Belle Plaine; and authorize contacted persons to respond to any
questions asked of them.

I release those persons, employers, and organizations from any liability for damage in providing this information to the City of
Belle Plaine.

___________________________________________ _______________________________________
(Signature of Applicant) (Date)

Parent/Guardian must sign if applicant is under the age of 18 years of age.

___________________________________________ _______________________________________
(Signature of Parent/Guardian) (Date)

STATE OF MINNESOTA
COUNTY OF _______________

This instrument was acknowledged before me on _______ day of ______________________, 20_____ by

_________________________________.

____________________________________ _____________________________________
****Notary Public ****Notary Stamp

My Commission Expires: ______________________

****Must be Notarized and signed by Notary in order for a criminal history to be completed.
The expiration of this authorization shall be for a period of no longer than one year from the date of my signature.

This Informed Consent meets the criteria set out in Minnesota Statutes 13.05, Subdivision 4, Paragraph D)

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 TENNESSEN WARNING

In accordance with the Minnesota Government Data Practices Act, The City of Belle Plaine is required to inform
you of your rights as they relate to the private information collected from you. Private data is information which is
available to you, but not to the public. The personal information we collect about you is private. Minnesota
Statutes 130.04 and 13.43 are two sections that govern what affects you as an applicant for employment with the
City of Belle Plaine. All data collected is considered private except for the following:

1. Your Veteran’s status

2. Relevant test scores
3. Your rank on our eligibility list
4. Your job history
5. Your education and training
6. Your work availability

Your name is considered private information, however, if you are selected to be interviewed as a finalist, your
name becomes public information.

The data supplied by you may be used for such other purposes as may be determined to be necessary in the
administration of personnel policies, rules and regulations of the City of Belle Plaine. Furnishing social security
numbers, date of birth (unless a minimum age is required), sex, age group, and disability data is voluntary, but
refusal to supply other requested information will mean that your application for employment may not be
considered.

Private data is available only to you, appropriate City employees, and others as provided by state and federal law
who have a bona fide need for the data. Public data is available to anyone requesting it and consists of all data
furnished in the application for employment which is not designated in this notice as private data.

Except for race, sex, age, and disability data, the information you give us about yourself is needed to identify you
and to assist the City of Belle Plaine in determining your suitability for the position for which you are applying.
Race, sex, age, and disability data are used in summary form by the City of Belle Plaine to monitor protected
class employment and to meet federal state and local reporting requirements.

I declare that I have read and understand the information given above regarding the Minnesota Data Privacy Act.

____________________________________________________________________
Applicant’s Printed Name

____________________________________________________________________
Applicant’s Signature Date

Please return all completed applications to:

City of Belle Plaine
218 North Meridian Street
P.O. Box 129
Belle Plaine, MN 56011.

**If submitting application electronically, please type your name in the Signature space above, and check this box in lieu of
your signature .

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 City of Belle Plaine
Affirmative Action Applicant’s Information

To All Applicants:

The following information in no way affects you as an individual applicant. This information will be used to find out
how effective our recruitment efforts are in reaching all segments of the population and in validation of our selection
methods. The information will not be maintained in personnel files and it will not be made available to any person
involved in decisions affecting an individual’s appointment or promotion to a position. Although providing this
information is voluntary, it is important that all applicants answer these questions so that we may take steps to
prevent discrimination in the recruitment and selection of employees for public service.

Position applying for: _______________________ Department: ________________________

What sex are you? ___Male ____Female ____Other _____________

Of the following, of what racial/ethnic group do you consider yourself?

___American Indian/Alaskan Native

___African American
___Asian and Pacific Islander
___Spanish or Mexican American
___Caucasian
___Other ______________

Do you have a disability? ___Yes ___No

How did you learn about this job opening?

___Local (City) Paper

___Minority or Female Publication/Organization
___School
___City Employee
___State Job Service
___Walk-In
___Posting in City Hall
___Other ________________

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