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Thomas RogitschDate Received: / t, j"TDIA The City of Scandia welcomes you as an applicant for employment. It is the policy of the City of Scandia to provide equal opportunity to all employees and applicants for employment. The City of Scandia will not discriminate against or harass any employee or applicant for employment because of race, color, creed, religion, national origin, sex, disability, age, marital status, sexual orientation, or status with regard to public assistance. Our employment decisions are made on the basis of individual ability and merit. Upon request, accommodations will be provided to applicants in accordance with American with Disabilities Act (ADA). Please call (651) 433-2274. Applicant's Last Name RCN 617-,sC H First _ 7' MD M,6 �; Middle J 0HIL' Position Applying For: PglBLTC W OKA- s pZREC re /C APPLICATION INSTRUCTIONS: To ensure that your application will be accurately processed, please review the following: (1) Please print or type when completing this form. (2) Complete a separate application form for each position opening you apply for, following instructions completely and signing your application where required. (3) There may be a supplemental application with additional questions for the position, which must be submitted in order for your application to be considered complete. (3) Be specific and complete when filling out the Employment History section. Application forms that are incomplete will be removed from further consideration. If additional space is needed to complete your employment history, you may make copies of that page.. A resume may be attached to the completed application. (4) Applications must be received by the advertised closing date and time. You may fax or e-mail a copy of your application by the deadline, but the original should be received in our office not later than one week following the closing of the application period. When the stated deadline is past, all applications will be reviewed and evaluated to determine how well each applicant is suited for the position opening. (5) Interviews will be conducted by the City Administrator and/or the City Council. Others may be involved as needed. After discussion, they will select the best applicant for the position. (6) The City Administrator will inform the successful applicant and arrange a starting date. Applicants will be notified by mail that the position has been filled. RETURN COMPLETED APPLICATION FORM TO: Neil Soltis, City Administrator City of Scandia 14727 2091h St. N. Scandia, MN 55073 Telephone: (651) 433-2274 Fax: (651) 433-5112 E-mail: n.soltis6bci.scandia.mn.us The City of Scandia is an Equal Opportunity Employer �► TENNESSEN WARNING In accordance with the Minnesota Government Data Practices Act, the City of Scandia is required to inform you of your rights as they relate to the private information collected from you. Private data is information that is available to you, but not the public. The personal information we collect about you is private. Minnesota Statutes 13.04 and 13.43 are two sections that govern what affects you as an applicant for employment with the City of Scandia. 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 Scandia. 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 that 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 Scandia 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 Scandia 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 Practices Act. Applicant's Printed Name: j o Ori GrTSG H Applicant's Signature: X -�rC Date: q ♦ PERSONAL INFORMATION NAME / ADDRESS / PHONE: Last Name: R 0 PS 4 TSGAl First Name: Middle: JO H ^ Address: 1 '2 3 j Plirt,,o,(-10 , City: L -rN /z 0101 State: l'►'1 /V. Zip: �'-570 t1 S Telephone: C E cc, 6 $1 , q 610 - q q 7 Telephone: f- vme 6 Q - of 3 3 - 2,7 Email: tom ron1r �cn ; 7� Between hours of Ar -y 7.Tmt,-,r and Between hours of -9:Q-0 A+'►'1 and f V,- 00 Pt" Are you under 18 years of age?..................................................................................... KNo ❑Yes Ifso, are you 16 years of age or older?,........................................................................... ❑ No ❑ Yes EDUCATION Educational Institution High School College College Other (Specify) Name and Address of Institution Course (Major/Minor) BRAD y fiS, wEsr sT P�y� MA,. G�y DRIVER'S LICENSE Level of Did you Education Graduate _ _J (Y/N) 12 TN I ye $l List Diploma or Degree Awarded 2GH S'C#Vice. ItfPcow,1► (Only complete this section if a driver's license is re aired for the Position you area 1 in for.) Driver's License # A 9'0 (0 3 8 7 7 f 0 6 License Class (A, B, C, D) State in which license is issued: M N. Expiration Date: 10 -05' OTHER LICENSES & CERTIFICATES ra -tq Please list any other licenses, registrations, or certifications that are required or pertinent to the position you are applying for. If this licensing, etc., is required for the position, and you fail to include a photocopy of it with your application form, your name will be removed from further consideration for the position. If this licensing is not required for the position, but you feel it is relevant and may be an item for which we are awarding points, please indicate below for credit to be awarded. i I ype of License or Certificate I Licensing Agency Expiration License Number Date * * Attach a copy of each license or certificate * * EMPLOYMENT HISTORY ♦ The City of Scandia uses a 100 -point system to assign value to the experience and training that relates most closely to the position you are applying for. Your experience and training will be scored using the experience and training value system designed for this position. Those applicants (typically the top 6 to 8) with the highest number of total points will be advanced for additional consideration. In order to receive the correct points and credit for the knowledge and skills you have acquired, it is absolutely necessary that you are specific when describing these skills. Do not use a single general statement to describe the duties you have performed. List each major duty performed for each position held within the past five years. Whether you are describing your experience as a clerical worker or a truck driver, list each duty separately and be specific. Describe duties in specific terms, such as "performed word processing using Word," or "operated forklift, front end loader, and back hoe." Statements such as "performed general clerical work" or "operated heavy equipment" are too general. ♦ Please be specific in stating the dates of employment and number of hours you worked per week for each job experience indicated. We need this information to properly score your experience. If hours worked per week vary, please use the average number of hours worked per week. ♦ Complete the boxed in "Length of Employment" section only for positions held within the past five years, but please do include all of your relevant work experience in the Employment History section. ♦ Please give accurate and complete information. List your present or most recent experience first. * DO NOT MARK YOUR APPLICATION "Please see resume." * PRESENT OR MOST RECENT EMPLOYER Employer: 6/91 L Ey A14195ERs F i May we contact this employer? ❑ No )CYes Employer Address: / 3Z (�o�sD N�w'Po2T' . znr seg rig �r'o Employer Phone Number: 6 rf - q > q - -q 7 Y Y Supervisor's Name & Title: IC 15 V rltl JQW/ r011-1 PROQ " G T-Co1" /"6-#"A 6 A.7A Your Job Title: (1)Azvr6,vt tvc c ofegetvss7olg verage Number of Hours Worked per Week: Numbers and types of positions you supervised: „�=f ' �►"rg►`', fi9PAX4ArX4 V ,Karo 146oAe yr �a .�; tam-sw«' Reason for Leaving. f® FAAM Fucc. Ttwre -Envoi SEPT 7-017- jo i HE 1"lz�f T Your Duties & Responsibilities: S'qPf-R V-cfC -1 AEeEch►TE' /9G6 M19rfvT FPA B`t1"c0��s �Q�LP/ytFd�i �EfEa��� D`GEc�v�s�-r cv�a h curry ��+OG�rs c��ra��r�°.�s /f�+�c txfr BF foohe- OF rt4c Dates of Employment: If less than 5 years ago, indicate dates of employment: pec. z0 o & to SEPT. ' 2 of Z - (month & year) (month & year) If more than 5 years ago, only indicate how long you worked there: _ years months PREVIOUS EMPLOYER Employer: U•_�, 1700p,S May we contact this employer? ❑ No XYes Employer Address: 1760 5" 5-'/T#, /9 i/E, IvegrH P�yMvgrH M i", SS Y Z Employer Phone Number: 74;? _, ss 7 - 2 2 Supervisor's Name & Title: R -re-# Pots—&G& - TRnr+4,ovlerlt rlor✓ s� ev o,4g -or5elt Your Job Title: 90"rE Average Number of Hours Worked per Week: Numbers and types of positions you supervised: _ 0— Reason " Reason for Leaving: TO RE ry1?1%,- 7-0 P f<X, Your Duties & Responsibilities: 9R-rt,,6 f0s"S OFi-ti,-eA pw:i4r.,F004 WEe�.J) v - PIM. & cArE , s- o si e e g olgsR 's 4 M�9 rti T. Dates of Employment: If less than 5years ago, indicate dates of employment: (month & year) If more than 5 Vears ago, only indicate how long you worked there: 13 PREVIOUS EMPLOYER to (month & year) years Y months Employer: 13/9,rt IV qR tF-�Iz-I- May we contact this employer? ❑ No RYes Employer Address: I � 2-,5, b19 -c . F, P d Ry NFWPo4 r'" + M tNH'E 5e r/9 . 1-9-0 g y` Employer Phone Number: Supervisor's Name & Title Your Job Title: PR0D#6rXVA1 S4(?XR1wTEN�erage Number of Hours Worked per Week: 5-0 Numbers and types of positions you supervised: SEyEieAz- foRmR,-- qo re loo WVAk4 t Reason for Leaving: 7-0 TAV F4 Am x:11-6 FuI-e- rrA145 Your Duties & Responsibilities: /9(.4 OF R �r'N,=rvcz �{ /9RGE wl�ocE Dates of Employment: If less than 5 years ag , indicate dates of employment: to (month & year) If more than 5 years ago, only indicate how long you worked there: Iq years (month & year) months PREVIOUS EMPLOYER Employer: S Tf)wD A410 C o/vfif_ Y04, May we contact this employer? ❑ No?❑ Yes Employer Address: 2 WO 6 11,C All r MIN i. Employer Phone Number: Al oiv6gr PtAiv_T- Supervisor's Name & Title: 6402646 561.41/4 6 PR 0,00 r-rOfV Your Job Title: C [.455 /9 WEE-0-,_P�P Average Number of Hours Worked per Week: Numbers and types of positions you supervised: Reason for Leaving: PL/9/v—/ C. 1-0 SED D4U4/✓ Your Duties & Responsibilities: C t li 5 S/9 C E R T>~f.TE,P WEGDd:!�I� - To 00 pR�dcrcT2or� �'FGDt�G Dates of Employment: If less than 5 years ago, indicate dates of employment: (month & year) to (month & year) If more than 5 years ago, only indicate how long you worked there: .7 --years 6 months + PROFESSIONAL REFERENCES List people who know you well, preferably from a work environment and not an acquaintance or relative. Name GR9 6 w Y11 T r Address 1 0001 J040"' Ave. 1119Srrfv6 Home Phone C5'1 -07- $y 7q MA- S�,0 -�3 Work Phone S/9 r'► E Occupation srA� Af yj- 6R0� ,� gf}r�� r Fo �►� Name J 01t1y P11Z t CY Address 17 L/5' Home Phone GFj - q 578 " 3 L1 2 (_i /N'6W Po,e r M /V. Work Phone 1? 6j - Lj sq - 7 Y Y Occupation 0, Foy /j�¢1��z Name J041tv LAK SEN Address f 0 Z7 RA M sE{/ f r, Home Phone—(o i Z -366 - c1 V 6 llfis, xwcG mp. 5TO 3�, Work Phone SA rn JOE Occupation /gr 6,64r EyS rt' SV + CRIMINAL HISTORY/ BACKGROUND CHECKS The City of Scandia conducts criminal history and driving license background checks on all regular full- time or part-time employees. The City may also conduct criminal history or driving license background checks on temporary or seasonal employees in positions which work directly with children or vulnerable adults, positions which involve driving as part of the duties, and positions which work directly with financial records and cash receipts. Background checks will be generally be conducted after an interview has taken place, but before a conditional offer of employment is made. For positions within the Fire Department, background checks may be conducted prior to an interview and any other testing that may be required as part of the hiring process. For all positions, the city will look at the type of conviction and whether it is directly related to the job for which you are applying. Candidates for positions working with children will not be selected if they have been convicted of any crime listed in the Child Protection Worker Act (Minnesota Statutes 299C.61 & 62). Generally, this includes child abuse crimes, murder, manslaughter, felony level assault or any assault crime committed against a minor; kidnapping, arson, criminal sexual conduct, and prostitution -related crimes. Before any applicant is rejected on the basis of criminal conviction, he or she will be notified in writing and will be given any rights afforded by Minnesota Statutes Chapter 364. This includes the right to show evidence of rehabilitation. I declare that I have read and understand the information given above regarding criminal history and background checks. Applicant's Printed Name: #oo7 fi 5 ,10H tv R ©tiGzrsG ff Applicant's Signature f /&4— Date: 4 / z 7116 r CLAIM FOR VETERAN'S PREFERENCE The eligibility requirements for veteran's preference are listed below. Read them carefully to see if you qualify. If you do wish to receive preference, be sure to complete this section. Providing the information in this section is voluntary. You must do so if you wish to obtain the preference. Veteran Eligibility for Open Competitive Position (5 Points) Must be a U.S. Citizen or resident alien who has separated under honorable conditions: (1) After serving on active duty for 181 consecutive days, or (2) By reason of disability incurred while serving on active duty. Disabled Veteran Eligibility for Open Competitive Position (10 Points) Must have a compensable service connected disability as adjudicated by the United States Veteran's Administration or by the Retirement Board of the several branches of the armed forces and the disability must exist at the time preference is claimed. Disabled Veteran Eligibility for Promotional Position (5 Points) Must, at the time of election to use preference, be entitled to disability compensation for a permanent service -connected disability rated at 50% or more and the position for which you are applying must be the first promotion after entering public employment. Eligibility as a Spouse of a Deceased or Disabled Veteran Must be a spouse of either a deceased veteran or the spouse of a disabled veteran who. because of a disability, is unable to qualify for the particular position due to his/her disability and who would have or does meet the criteria for one of the above -listed preferences. ALL APPLICANTS CLAIMING VETERAN'S PREFERENCE MUST ATTACH A COPY OF HIS/HER FORM DD214. FAILURE TO DO SO MAY RESULT IN LOSS OF VETERAN'S PREFERENCE ELIGIBILITY. City of Scandia Veteran's Preference Claim Form For V.A. Use Only: Is the veteran named below rated as having a compensable service -related disability? ❑ No ❑ Yes % of Disability By Date Name of Veteran (last — first — middle) Name of Applicant — if different than veteran (last — first — middle) Address City State Zip Classification To Be Completed by Veteran or Spouse of Deceased Veteran (1) Are you a U.S. Citizen or resident alien? ................................ ........... ................................. ............................................. ❑ No ❑ Yes (2) Were you honorably discharged from military service? ..................... ........... ................................................................... ❑ No ❑ Yes (3) Were you separated from military service after serving active duty for at least 181 consecutive days? .......................... El No ❑ Yes (4) Do you currently have a compensable service -related disability? ........................... .................... .................................... ❑ No ❑ Yes (5) Branch of Service . Date of Discharge Serial Number Type of Separation Date of Entry For spouse of deceased veteran, date of death If Spouse of Disabled Veteran, please answer the following: If spouse is disabled, please explain why your spouse does not qualify for this position Claim Number (if disabled) State Claim is Filed In Signature of Veteran Social Security Number Date EMPLOYEE CERTIFICATION Before signing this application, please read the following waiver carefully. (1) 1 have read and understand the job announcement for the position for which I am applying and certify that the answers given in this application are true and complete to the best of my knowledge. (2) 1 authorize all current and previous employers to release job-related information upon the written request of the City of Scandia. However, I understand that if, in the Employment History section, I have answered "No" to the question, "May we contact this employer?," contact with the employer will not be made without my specific authorization. (3) 1 authorize the City of Scandia to verify all information on this application to determine whether or not I am qualified for the position for which I am applying. (4) 1 understand that providing false information on this application may result in dismissal from any position gained on the basis of that false information. Applicant's Printed Name: lie f"/i 0/V e --%f Applicant's Signature: �^J-- /..R Date: q/ Z 71`6 * BEFORE YOU SUBMIT YOUR APPLICATION, HAVE YOU .... . Q Thoroughly read this entire application with special attention to the Tennessen Warning? Q Signed this application in all the required places? This application will not be accepted without all necessary signatures. • Tennessen Warning ■ Criminal History/ Background Checks + Claim for Veteran's Preference, if applicable Employee Certification 0 Provided sufficient information so that proper credit for training and experience are given? 0 Completed the claim for Veteran's Preference if applicable to you? Also, a copy of your Form DD214 must be submitted at the time of application to determine your eligibility for points. Q Included copies of all required licensing and/or certifications? 9/05 The City of Scandia needs your cooperation in the completion of this form. It will enable the City to report accurate information to both the State and Federal governments. ♦ AFFIRMATIVE ACTION APPLICANT 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: P(46&16 li10Kf 3 PJ O(ECTOA PC49&,CG Walks Instructions: Check the choice that answers each of the following questions. (1) What sex are you? XMale ❑ Female (2) 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 White Other (3) Do you have a disability? ® No ❑ Yes (4) How did you learn about this job opening? Country Messenger X Forest Lake Times St. Paul Pioneer Press League of MN Cities Website City Employee City Website Walk -In Posting at Community Center Other (be specific): I , �`; �� �•�> - Position: Public Works Director SC -I Please furnish as complete information as possible, attaching additional pages if necessary. This form is part of your employment application. # SUPPLEMENTAL APPLICATION Applicant's Last Name PDfV G.z'T 5'6,f First TyoBIAf Middle 1. Describe your knowledge of and experience with road construction and maintenance. LTff octQ p EQ�tP� r ft�D e4IO1tJCrW6 w�Tfi co�TiLr3�j-��S G2�D�Z 5 2. Describe your knowledge of and experience with operation and maintenance of heavy equipment as employed in road, drainage and other public works projects. T Ps F'i4en=ce4 w.rr,l 64174r--5 5 1-0 D R' 0,1D f � oc'fT/}C C D f 6ge-VFi(Tf Wrrff ��fOGf��S F�'� SSG/� /��o✓�cT-i 3. Describe your knowledge of and experience with building and grounds maintenance. -:r- w,14 r F/fctc,f ?' / F/10E7 A,eF S TO f4 a NAAW 6 To �---/t lc.r-4-,6 ert- 61t wt lay' M 4�� 1 4. Describe your knowledge of and experience with developing and implementing policies for operation and maintenance of public infrastructure (such as pavement maintenance, snow and ice control, sewer and/or water systems) or equipment. A6.L SNc ui AaMr cWct Fe 441►`o-04(o"w.w *r—o Fort r rt4afy y A" f,g w" /9v -,o C4-,4 rje/11 6 th / cs'l� •/'ri �G��9%,Bp DQE' ey s/r�P Slgff �� co.Yr/ty�n'��t��� D�i��> ^64 5. Describe your knowledge of and experience with subsurface sewage treatment systems or water systems. �} ►t�� Gtr© A I,- rWA6 WAOs PICDO O u7- le y 774,6c- 6. Describe your knowledge of and experience with work safety standards and implementation of OSHA regulations. W0/1&1:1416 wCTH f1A wF r�altE �}crvi4yS por-�6 �r� �T TO epl C u/ A60e-T Al -,O C� /'ay�•�� Pt -r rH O S6w 4rew , o r /1 gzcltog Tre).- -S C O pCTSO� y /9 �D P2f}eTrcrF �' 7. Describe your supervisory experience, including the positions and number of employees supervised. S M/$t�T,SkP�Fyrv�SD/� � ff4p FD�(Frt1�q.� ff�A !O �!S'57 A I'1'1FNtB�� S' pFD�D�� pa' tav�RKGoft� f}�v4 T.�'/rr� d� y��i/� 6f 440oelcrre �C ,#4o Wtr# QD T-0/00 w-PlLke< S Applicant's Last Name R O/VGrrSch` First 7-ff001 5 Middle J011,0 -- Applicant's Signature: X '1 r-��^� - zo,,� Date: 7A7 116 2 fiL�o 0 w�vel�ltmflfllrd If r �9 7 7 -o �c�t //100 �CT�o Fi9Rw! W16Af- Wdasw-y, face- ex0,04f ro✓��M/¢r�r, .1 XO S"fL.6t fi�E pewe my wrFe- AHd mys,ez.f, WC H4VR REoOc60 ry 2v r ffqv,.,c o F rf- m e ro )O em yq ' Tris S vP a�rr� tF r'RF s�.v rr o,