HomeMy WebLinkAbout10E - Data Practices
MEE ING DATE:
AGENDA #:
PREPARED BY:
AGENDA ITEM:
DISCUSSION:
CITY COUNCIL AGENDA REPORT
SEPTEMBER 15, 2003
10E
Susan Walsh, Assistant City Manager
CONSIDER APPROVAL OF A RESOLUTION ADOPTING CITY OF PRIOR
LAKE DATA PRACTICES PROCEDURES AND APPOINTING THE
RESPONSIBLE AUTHORITY AND COMPLIANCE OFFICIAL
History: The Minnesota Government Data Practices Act (Data Practices Act),
regulates the handling of all government data that are created, collected, received
or disseminated by a state agency, political subdivision or statewide system. The
Legislature has made several changes to the Minnesota Data Practices Act over
the past few years. In order to remain compliant with the Data Practices Act, staff
has prepared a Data Practices Procedures, which incorporates those changes.
The procedures will also assist city staff in complying with all of the regulations of
this very complex law.
Current Circumstances: The attached Data Practices Procedures sets out the
procedures on how staff will maintain all the data that is created, collected and
stored as well as how to respond to people requesting access to this data. Below
are overviews on the main sections of the procedures which have been prepared
in accordance with Chapter 13 of the State Statutes:
. Section 1. Introduction: States the City of Prior Lake Data Practices
Procedures are in compliance with the Data Practices Act.
. Section 2. Responsible Authority/Compliance Official: Under the Data
Practices Act, the city is required to have a Responsible Authority, who is
responsible for collection, use and dissemination of all city data, and a Data
Practices Compliance Official to answer questions and respond to concerns
from persons who are attempting to access Data. The Assistant City Manager
is the designated position for both responsibilities, and the attached resolution
appoints Assistant City Manager Susan Walsh as the City's Responsible
Authority and Compliance Official. The procedures also designate
department directors as designees of the Responsible Authority.
. Section 3. Access to Public Data: This section explains the criteria for
determining whether a request for data can be verbal or written; the time
frame for staff to respond to requests for data; providing public data in
electronic format and the fees the City will charge for providing the data. The
City's fees for providing photocopies are listed in Exhibit 2 of the procedures,
and charges for documents such as the City Code, Zoning Ordinance,
Comprehensive Plan, etc. are established annually by the City Council in the
annual fee schedule. This section also explains reasons the City may charge
additional fees for requested information that may have commercial value or
includes data that is developed with significant expenditure of public funds.
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PRACTICES POLICY AGENDA REPORT.DO~ EQUAL OPPORTUNITY EMPLOYER
. Section 4. Access to Data on Individuals: The Data Practices Act classifies
information on individuals as public, private or confidential. Appendix A of the
procedures lists all of the data maintained by the City that has a classification
other than public. Examples of non public data are certain personnel data, the
identity of a person making a complaint about a violation of the City Code or
Zoning Ordinance; and numerous law enforcement data. Section 5 also
describes who can have access to private data, the form the Responsible
Authority must complete when private or confidential information is requested,
time limits for staff to provide the data and how to collect and maintain juvenile
records classified as private data.
. Section 5. Denial of Access: In accordance with the Data Practices Act, this
section requires the Responsible Authority to provide the legal authority,
including the statutory section, when data is not accessible to the requesting
party.
. Section 6. Collection of Data on Individuals: This section addresses how the
city may lawfully collect and store data on individuals. If the City determines
private or confidential information is needed, the City must provide the
individual a Tennessen warning. This notice informs an individual why the
information is needed, whether the individual can refuse to provide the data,
what the consequences are if an individual supplies or refuses the data, and
what other persons or agencies are authorized by law to receive any of the
data collected. An employment application is a good example of a document
that includes a Tennessen warning.
. Section 7. Challenqe to Data Accuracv: This section sets out the process if
an individual would contest to the accuracy or completeness of the data
maintained by the City.
. Section 8. Data Protection: This section discusses the necessity for the City
to collect and maintain private and confidential information from individuals
such as applicants for licenses and from employees for tax, insurance and
emergency notification purposes. The Data Practices Act also requires the
City to ensure that private and confidential data is maintained in a secure
fashion and only accessible to authorized employees. This is applicable to
outside contracting parties who will be required to use and disseminate the
information consistent with the Data Practices Act.
. Section 9. Records Retention Schedule: This section references the General
Records Retention Schedule that was adopted by the City Council in May
1999. The purpose of the retention schedule is to have a plan for managing
the City's records and for having authority to dispose of records as indicated
on the schedule.
Conclusion: It is staffs recommendation that the Council approve the proposed
Data Practices Procedures and appoint the Assistant City Manager as the City's
Responsible Authority and Data Practices Compliance Official.
ISSUES:
The city attorney and staff have prepared the proposed procedures in accordance
with the Data Practices Act. Approval of the procedures will bring the City in
compliance with current requirements of Minnesota Statutes Chapter 13.
C:IDOCUMENTS AND SETTINGSIKELL YMILOCAL SETTINGSITEMPORARY INTERNET FlLESIOLK187\DATA
PRACTICES POLICY AGENDA REPORT. DOC
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ALTERNATIVES: (1) Motion to adopt a resolution approving the City of Prior lake Data Practices
Procedures and appointing the City's Responsible Authority and Compliance
Official.
(2) Defer action to the next regular City Council meeting.
RECOMMENDED
MOTION: 'Alternative NO.1.
REVIEWED BY:
C:IDOCUMENTS AND SETTINGSIKELL YMILOCAL SETTINGSITEMPORARY INTERNET FILESIOLK1871DATA
PRACTICES POLICY AGENDA REPORT.DOC
RESOLUTION 03-
16200 Eagle Creek Avenue S.E,
Prior Lake, MN 55372.1714
A RESOLUTION ADOPTING THE CITY OF PRIOR LAKE
DATA PRACTICES PROCEDURES AND APPOINTING
THE RESPONSIBLE AUTHORITY AND COMPLIANCE OFFICIAL
Motion By:
Second By:
WHEREAS, Minnesota Government Data Practices Act, which is Chapter 13 of Minnesota Statues, is a
state law that controls how government data are collected, created, stored, used and
released; and
WHEREAS, Legislative amendments to the Minnesota Government Data Practices necessitates the
preparation of a new Data Practices Procedures; and
WHEREAS, City Council has reviewed the City of Prior Lake Data Practices Procedures; and
WHEREAS, Minnesota Government Data Practices Act requires the City Council to designate a
Responsible Authority who is responsible for collection, use, and dissemination of any City
data; and
WHEREAS, Minnesota Government Data Practices Act requires the City Council to designate a Data
Practices Compliance Official to receive questions or concerns regarding problems in
obtaining access to data or other data practices problems.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF PRIOR LAKE, MINNESOTA
that:
1. The recitals set forth above are incorporated herein.
2. The City Council approves the City of Prior Lake Data Practices Procedures.
3. The City Council appoints Assistant City Manager Susan Walsh as the City of Prior Lake
Responsible Authority and Data Practices Compliance Official.
PASSED AND ADOPTED THIS 15th DAY OF SEPTEMBER, 2003.
Haugen Haugen,
Blomberg Blomberg
LeMalr LeMair
Petersen Petersen
Zieska Zieska
YES
NO
City Manager, City of Prior Lake
www.cityofpriorlake.com
Phone 952.447.4230 / Fax 952.447.4245
CITY OF PRIOR LAKE
Data Practices Procedures
A dt:pteJ. SepteJ'rb!r 15, 2003
Gty of Prior Lal<e
16200 Eagle Creek Avenue SE
Prior Lal<e, MN 55372
Phone 952,447.4230. Fax 952.447.4245
16200 Eagle Oeek Ave. S.E., Prior Lake, Minnesota 55372-1714 / Ph. (952) 447-4230 / Fax (952) 447-4245
AN EQUAL OPPORTIlNITY EMPLOYER
CITY OF PRIOR LAKE
DATA PRACTICES PROCEDURES
INDEX
Subject
Page
1. Introduction........................................................................................................ 1
2. Responsible Authority and Data Practices Compliance Official........................... 1
3. Access to Public Data ......................................................................................... 1
3.1 People Entitled to Access............................................................................. 1
3.2 Form of Request .......................................................................................... 1
3.3 Time Limits................................................................................................... 1
3.4 Fees............................................................................................................. 2
4. Access to Data on Individuals ............................................................................. 2
4.1 People Entitled to Access............................................................................. 2
4.2 Form of Request .......................................................................................... 3
4.3 Identification of Requesting Party................................................................. 3
4.4 Time Limits................................................................................................... 3
4.5 Fees............................................................................................................. 3
4.6 Summary Data............................................................................................. 3
4.7 Juvenile Records.......................................................................................... 4
5. Denial of Access ................................................................................................ 5
6. Collection of Data on Individuals........................................................................ 5
7. Challenge to Data Accuracy .............................................................................. 5
8. Data Protection.................................................................................................. 6
8.1 Accuracy, Completeness and Currency of Data.......................................... 6
8.2 Data Safeguards......................................................................................... 6
9. Records Retention.............................................................................................. 7
ON: 195319 Vor: 4
EXHIBITS
1. List of Responsible Aulhority and Designees .............................................................8
2. Photocopy Charge Policy........................................................................................... 9
3. Consent to Release Private Data............................................................................. 10
4. Information Disclosure Request............................................................................... 11
5. Government Data Access and Nondisclosure Agreement .......................................12
6. Notice To Persons Under Age of 18 ........................................................................14
7. Data Practices Advisory........................................................................................... 15
8. Sample Contract Provision ...................................................................................... 16
APPENDICES
Appendix A. Data Maintained by the City of Prior Lake Classified as Not Public
Appendix B. Forms Which Request Private or Confidential Data
ON: 195319 Ver: 4
CITY OF PRIOR LAKE
DATA PRACTICES PROCEDURES
SECTION 1. INTRODUCTION
These procedures are adopted to comply with the requirements of the Minnesota Government
Data Practices Act (the "Act"), specifically Minn. Stat. ~~ 13.03, Subd. 2 and 13.05, Subd. 5 and
8.
SECTION 2. RESPONSIBLE AUTHORITY AND DATA PRACTICES COMPLIANCE
OFFICIAL
The Assistant City Manager is the Responsible Authority and Data Practices Compliance
Official for compliance with the Act. The Responsible Authority and Data Practices Compliance
Official has designated certain other City employees to assist in complying with the Act. These
designees are listed on attached Exhibit 1.
SECTION 3. ACCESS TO PUBLIC DATA
All information maintained by the City is public unless it is classified by state or federal law as
nonpublic or protected nonpublic, or with respect to data on individuals, as private or
confidential.
Section 3.1 People Entitled to Access
Any person has the right to inspect and copy public data. The person also has the right to have
an explanation of the meaning of the data. The person does not need to state his or her name
or give the reason for the request.
Section 3.2 Form of Request
The request for public data may be verbal or written. The Responsible Authority or designee
may require a verbal request to be made in writing whenever a written request will assist the
Responsible Authority or designee in performing his or her duties.
Section 3.3 Time Limits
Section 3-3.1 Requests: Requests will be received and processed only during normal
business hours.
Section 3-3.2 Response: If the request is made by someone other than the data subject
and a response cannot be provided at the time of the request, a response must be provided
as soon as reasonably possible. If the request is made by the data subject, the response
must be immediate, if possible, or within ten (10) days of the date of request, excluding
weekends and legal holidays.
Section 3-3.3 Form of Copies: Where public data is maintained in a computer storage
medium, the City must provide copies of the public data in electronic form, upon request, if
DN: 195319 Ve.: 4
a copy can reasonably be made in that form. The City is not required to provide the data in
an electronic format or program that is different from the format or program in which the City
maintains the data. The City may charge a fee for the actual cost of providing the copy.
Section 3.4 Fees
Section 3-4.1 No Fees Charqed: No fee may be charged for merely inspecting data.
When copies are requested and a fee is charged for copies, no fee may be charged for time
spent separating public from not public data.
Section 3-4.2 Fee Charqed: Fees may be charged only if the requesting person asks for a
copy or electronic transmittal of the data. Fees will be charged according to the City's
standard photocopying policy, attached hereto as Exhibit 2. If the time required to search
for and retrieve the requested data is significant, the fee will include the actual cost of
searching for, retrieving and copying or electronically transmitting the data.
Section 3-4.3 Additional Fees: The Responsible Authority may charge an additional fee if
the copies of data have commercial value and are a substantial and discrete portion of a
formula, pattern, compilation, program, device, method, technique, process, database or
system developed with significant expenditure of public funds. This additional fee must
relate to the actual development costs of the information. The Responsible Authority will,
upon request, provide sufficient documentation to explain and justify the fee being charged.
SECTION 4. ACCESS TO DATA ON INDIVIDUALS
Information about individual people is classified by law as public, private or confidential. A list of
the information maintained by the City that has a classification other than public is contained in
Appendix A. The forms used to collect private and confidential information are contained in
Appendix B.
Section 4.1 People Entitled to Access
Section 4-1.1 Public Information: Public information about an individual may be shown or
given to anyone.
Section 4-1.2 Private Information: Private information about an individual may be shown or
given to:
a. The individual data subject, but only once every six months, unless a dispute has
arisen or additional data has been collected or created.
b. A person who, or entity which, has been given access by the express written
consent of the individual data subject. This consent must be on the form
attached as Exhibit 3, or on a reasonably similar form.
c. People who are authorized access by federal, state or local law or court order.
d. People about whom the individual was advised at the time the data was
collected. The identity of those people must be part of the Tennessen warning
described below.
ON: 195319 Ver: 4
e. People within the City staff, the City Council and outside agents under contract
with the City (e.g., insurance adjusters or attorneys) whose work assignments or
responsibilities reasonably require access.
Section 4-1.3 Confidential Information: Confidential information may not be given to the
individual subject of the data, but may be shown or given to:
a. People who are authorized access by federal, state, or local law or court order.
b. People within the City staff, the City Council, and outside agents under contract
with the City (e.g., insurance adjusters or attorneys) whose work assignments or
responsibilities reasonably require access.
Section 4.2 Form of Request
Any individual may request verbally or in writing as to whether the City has stored data about
that individual and whether the data is classified as public, private, or confidential.
All requests to see or copy private or confidential information must be in writing. An Information
Disclosure Request, attached as Exhibit 4, must be completed to document who requests and
who receives this information. The Responsible Authority or designee must complete the
relevant portions of the form. The Responsible Authority or designee may waive the use of this
form if there is other documentation of the requesting party's identity, the information requested,
and the City's response.
Section 4.3 Identification of Requesting Party
The Responsible Authority or designee must verify the identity of the requesting party as a
person entitled to access. Verification can be through personal knowledge, presentation of
written identification, comparison of the data subject's signature on a consent form with the
person's signature in City records, or other reasonable means.
Section 4.4 Time Limits
Section 4-4.1 Requests: Requests will be received and processed only during normal
business hours.
Section 4-4.2 Response: If the request is made by someone other than the data subject
and a response cannot be provided at the time of the request, a response must be provided
as soon as reasonably possible. If the request is made by the data subject, the response
must be immediate, if possible, or within ten (10) days of the date of request, excluding
weekends and legal holidays.
Section 4.5 Fees
Fees may be charged in the same manner as for public information.
Section 4.6 Summary Data
ON: 195319 Vor: 4
Summary data means statistical records and reports derived from data on individuals but which
do not identify an individual by name or any other characteristic that could uniquely identify an
individual. Summary data derived from private or confidential data is public unless classified by
state or federal law as not public. The Responsible Authority or designee will prepare summary
data upon request, if the request is in writing and the requesting party pays for the cost of
preparation. The Responsible Authority or designee must notify the requesting party about the
estimated costs within ten (10) days after receiving the request and collect those costs before
preparing or supplying the summary data. If the summary data cannot be prepared within ten
(10) days, the Responsible Authority must notify the requester of the anticipated time schedule
and the reasons for the delay.
Summary data may be prepared by "blacking out" personal identifiers, cutting out portions of
the records that contain personal identifiers, programming computers to delete personal
identifiers, or other reasonable means.
The Responsible Authority may ask an outside agency or person, including the person
requesting the summary data, to prepare the summary data if (1) the specific purpose is given
in writing, (2) the agency or person signs a nondisclosure agreement that meets the
requirements of Minnesota Rules, Chapter 1205.0700, Subpart 5, and (3) the Responsible
Authority determines that access by the outside agency or person will not compromise the
privacy of the private or confidential data. The Responsible Authority may use the form
attached as Exhibit 5.
Section 4.7 Juvenile Records
The following applies to private (not confidential) data about people under the age of 18.
Section 4-7.1 Parental Access: In addition to the people listed above who may have
access to private data, a parent may have access to private information about a juvenile
data subject. "Parent" means the parent or guardian of a juvenile data subject, or an
individual acting as a parent or guardian in the absence of a parent or guardian. The parent
is presumed to have this right unless the Responsible Authority or designee has been given
evidence that there is a state law, court order, or other legally binding document which
prohibits this right.
Section 4-7.2 Notice to Juvenile: Before requesting private data from juveniles, city
personnel must notify the juveniles that they may request that the information not be given
to their parent(s). This notice should be in the form attached as Exhibit 6.
Section 4-7.3 Denial of Parental Access: The Responsible Authority or designee may deny
parental access to private data when the juvenile requests this denial and the Responsible
Authority or designee determines that withholding the data would be in the best interest of
the juvenile. The request from the juvenile must be in writing stating the reasons for the
request and signed by the juvenile. In determining the best interest of the juvenile, the
Responsible Authority or designee will consider:
a. Whether the juvenile is of sufficient age and maturity to explain the reasons and
understand the consequences of denying parental access;
ON: 195319Ver: 4
b. Whether denying parental access may protect the juvenile from physical or
emotional harm;
c. Whether there are reasonable grounds to support the juvenile's reasons for
denying parental access; and
d. Whether the data concerns medical, dental or other health services provided
under Minnesota Statutes Sections 144.341 to 144.347. If so, the data may be
released only if failure to inform the parent would seriously jeopardize the health
of the minor.
The Responsible Authority or designee may also deny parental access without a request
from the juvenile under Minnesota Statutes Section 144.335, or under any other state or
federal statute that allows or requires denial of parental access and that provides standards
for denying parental access.
SECTION 5. DENIAL OF ACCESS
If the Responsible Authority or designee determines that the requested data is not accessible to
the requesting party, the Responsible Authority or designee must inform the requesting party
orally at the time of the request or in writing as soon as possible afterward. The Responsible
Authority or designee must give the specific legal authority, including statutory citation, for
withholding the data. The Responsible Authority or designee must place an oral denial in
writing upon request, which must also include the specific legal authority for the denial.
SECTION 6. COllECTION OF DATA ON INDIVIDUALS
The collection and storage of information about individuals will be limited to that necessary for
the administration and management of programs specifically authorized by the state legislature,
city council or federal government.
When an individual is asked to supply private or confidential information about himself or
herself, the City employee requesting the information must give the individual a Tennessen
warning. This warning must contain the following:
. the purpose and intended use of the requested data;
. whether the individual may refuse or is legally required to supply the requested data;
. any known consequences from supplying or refusing to supply the information; and
. the identity of other persons or entities authorized by state or federal law to receive the
data.
A Tennessen warning is not required when an individual is requested to supply investigative
data to a law enforcement officer, pursuant to Minn. Stat. Section 13.82, Subd. 7.
A Tennessen warning may be on a separate form or may be incorporated into the form which
requests the private or confidential data. See attached Exhibit 7, Data Practices Advisory.
ON: 195319 Ver: 4
SECTION 7. CHALLENGE TO DATA ACCURACY
An individual who is the subject of public or private data may contest the accuracy or
completeness of that data maintained by the City. The individual must notify the City's
Responsible Authority in writing describing the nature of the disagreement. Within thirty (30)
days, the Responsible Authority or designee must respond and either (1) correct the data found
to be inaccurate or incomplete and attempt to notify past recipients of inaccurate or incomplete
data, including recipients named by the individual, or (2) notify the individual that the
Responsible Authority believes the data to be correct. The Responsible Authority should
provide the data subject with a written statement that informs the data subject of the right to
appeal and should also provide a copy of Minnesota Rules, Chapter 1205.1600. Any data in
dispute will thereafter be disclosed only if the individual's statement of disagreement is included
with the disclosed data.
An individual who is dissatisfied with the Responsible Authority's action may appeal to the
Commissioner of the Minnesota Department of Administration, using the contested case
procedures under Minnesota Statutes Chapter 14. The Responsible Authority will correct any
data if so ordered by the Commissioner.
SECTION 8. DATA PROTECTION
Section 8.1 Accuracy, Completeness and Currency of Data
Section 8-1.1 Individuals who provide private or confidential information will be encouraged
to provide updated information when appropriate.
Section 8-1.2 All employees will be requested, and given appropriate forms, to provide
updated personal information to the appropriate supervisor, Assistant City Manager or
Finance Director, which is necessary for tax, insurance, emergency notification, and other
personnel purposes.
Section 8-1.3 Department heads should periodically review forms used to collect data on
individuals to delete items that are not necessary and to clarify items that may be
ambiguous.
Section 8-1.4 All records must be disposed of according to the City's records retention
schedule.
Section 8.2 Data Safeguards
Section 8-2.1 Private and confidential information will be stored in files or databases which
are accessible only to City employees with authorized access and which will be secured
during hours when City offices are closed.
Section 8-2.2 Private and confidential data must be kept only in City offices, except when
necessary for City business.
Section 8-2.3 Only those City employees whose job responsibilities require them to have
access will be allowed access to files and records that contain private or confidential
information. These employees will be instructed to:
ON: 195319 Ver: 4
a. not discuss, disclose or otherwise release private or confidential data to City
employees whose job responsibilities do not require access to the data;
b. not leave private or confidential data where non-authorized individuals might view it;
and
c. shred private or confidential data before discarding.
Section 8-2.4 When a contract with an outside party requires access to private or
confidential information, the contracting party will be required to use and disseminate the
information consistent with the Act. The City may include in a written contract the language
contained in Exhibit 8.
SECTION 9. RECORDS RETENTION
All data and records collected and maintained by the City must be disposed of according to the
City's records retention schedule, which is available upon request from the Assistant City
Manager.
ON: 195319 Ver: 4
EXHIBIT 1
CITY OF PRIOR LAKE
LIST OF RESPONSIBLE AUTHORITY AND DESIGNEES
Responsible Authority/Data Practices Record Type Responsibility
Compliance Officer
Susan Walsh, Assistant City Manager All Records
Designees
Robert Hutchins, Building Official Building Division
Sue McDermott, City Engineer Engineering Division
Ralph Teschner, Finance Director Finance Department
Bruce Sames, Fire Chief Fire Department
Don Rye, Community Development Director Planning Department
Bill O'Rourke, Police Chief Police Department
Bud Osmundson, Public Works Director Public Works Department
ON: 195319 Ver: 4
EXHIBIT 2
CITY OF PRIOR LAKE
PHOTOCOPY CHARGE POLICY
No charqe if:
1. Copy produced relates to standard copier paper sizes (i.e. 8 1/2 x 11", legal size or 11 x
17")
2. Prior lake resident
3. Prior lake business request for own use (not for client purposes)
4. Number is limited to 10 total sheets
5. Information to be copied must be routine and readily available
6. Copy charge of $.25 per copy in excess of 10 sheets
All other requesting parties will be charged the standard copy rate of $.25 per copy.
Document Charge: Fees for frequently requested documents, such as zoning ordinances,
maps, agenda and minutes are established in the annual fee schedule.
DN: 195319 Vo': 4
EXHIBIT 3
CITY OF PRIOR LAKE
CONSENT TO RELEASE PRIVATE DATA
I,
private data about me:
, authorize the City of Prior Lake to release the following
to the following person or people:
The person or people receiving the private data may use it only for the following purpose or
purposes:
This authorization is dated
and expires on
(The expiration cannot exceed one year from the date of the authorization, except in the case of
authorizations given in connection with an application for life insurance or noncancellable or guaranteed
renewable health insurance, and identified as such, two years after the date of the policy.)
I agree to give up and waive all claims that I might have against the City, its agents and
employees for releasing data pursuant to this request.
Signature
IDENTITY VERIFIED BY:
o Witness:
o Identification: Driver's License, State 10, Passport, other:
o Comparison with signature on file
o Other:
Responsible Authority/Designee
ON: 195319 Ver: 4
EXHIBIT 4
CITY OF PRIOR LAKE
INFORMATION DISCLOSURE REQUEST
Minnesota Government Data Practices Act
Completed by Requester:
REQUESTER NAME (LAST, FIRST, MIDDLE): DATE OF REQUEST:
STREET ADDRESS: PHONE NUMBER:
CITY, STATE, ZIP CODE: SIGNATURE:
DESCRIPTION OF THE INFORMATION REQUESTED:
Completed by Department:
DEPARTMENT NAME: HANDLED BY:
INFORMATION CLASSIFIED AS: ACTION:
a PUBLIC a APPROVED
a NON-PUBLIC a APPROVED IN PART (EXPLAIN BELOW)
a PRIVATE a DENIED (EXPLAIN BELOW)
a PROTECTED NON-PUBLIC
a CONFIDENTIAL
REMARKS OR BASIS FOR DENIAL INCLUDING STATUTORY CITATION:
PHOTOCOPYING CHARGES: IDENTITY VERIFIED FOR PRIVATE INFORMATION:
a NONE a IDENTIFICATION: DRIVER'S LICENSE,
STATE ID, etc.
a PAGES X $.25~ a COMPARISOON WITH SIGNATURE ON FILE
a PERSONAL KNOWLEDGE
a Special Rate: (attach explanation) a OTHER:
AUTHORIZED SIGNATURE:
DN: 195319 Va" 4
EXHIBIT 5
CITY OF PRIOR LAKE
GOVERNMENT DATA ACCESS AND NONDISCLOSURE AGREEMENT
1. AUTHORIZATION. City of Prior Lake ("City") hereby authorizes
("Authorized Party") access to the following government data:
2. PURPOSE. Access to this government data is limited to the objective of creating summary
data for the following purpose:
3. COST. (check applicable box)
D The Authorized Party is the person who requested the summary data and agrees to bear
the City's costs associated with the preparation of the data which has been determined to
be $
D The Authorized Party has been requested by the City to prepare summary data and will be
paid in accordance with attached Exhibit A.
4. SECURITY. The Authorized Party agrees that it and any employees or agents under its
control must protect the privacy interests of individual data subjects in accordance with the
terms of this Agreement.
The Authorized Party agrees to remove all unique personal identifiers which could be used
to identify any individual from data classified by state or federal law as not public which is
obtained from City records and incorporated into reports. summaries. compilations. articles,
or any document or series of documents.
Data contained in files, records, microfiche, laserfiche or other storage media maintained by
the City are the City's property and are not to leave the City's custody. The Authorized
Party agrees not to make reproductions of any data or remove any data from the site where
it is provided, if the data can in any way identify an individual.
No data which is not public and which is irrelevant to the purpose stated above will ever be
disclosed or communicated to anyone by any means.
The Authorized Party warrants that the following named individual(s) will be the only
person(s) to participate in the collection of the data described above:
ON: 195319 Ver: 4
ACCESS AND NONDISCLOSURE AGREEMENT
5. LIABILITY FOR DISCLOSURE. The Authorized Party is liable for any unlawful use or
disclosure of government data collected, used and maintained in the exercise of this
Agreement and classified as not public under state or federal law. The Authorized Party
understands that it may be subject to civil or criminal penalties under those laws.
The Authorized Party agrees to defend, indemnify, and hold the City, its officers and
employees harmless from any liability, claims, damages, costs, judgments, or expenses,
including reasonable attorneys' fees, resulting directly or indirectly from an act or omission
of the Authorized Party, its agents, employees or assignees under this Agreement and
against all loss by reason of the Authorized Party's failure to fully perform in any respect all
obligations under this Agreement.
6. INSURANCE. In order to protect itself as well as the City, the Authorized Party agrees at all
times during the term of this Agreement to maintain insurance covering the Authorized
Party's activities under this Agreement. The insurance will cover $1 ,000,000 per claimant
for personal injuries and/or damages and $1,000,000 per occurrence. The policy must
cover the indemnification obligation specified above.
7. ACCESS PERIOD. The Authorized Party may have access to the information described
above from to
8. SURVEY RESULTS. (check applicable box)
o If the Authorized Party is the requester, a copy of all reports, summaries, compilations,
articles, publications or any document or series of documents which are created from the
information provided under this Agreement must be made available to the City in its entirety.
o If the Authorized Party is a contractor of the City, all copies of reports, summaries,
compilations, articles, publications or any document or series of documents which are
created from the information provided under this Agreement must be provided to the City.
The Authorized Party may retain one copy for its own records but may not disclose it
without City permission, except in defense of claims brought against it.
Date:
ACCEPTED AND AGREED TO:
Authorized Party
Responsible Authority/Designee
ON: 195319 Ver: 4
EXHIBIT 6
CITY OF PRIOR LAKE
NOTICE TO PERSONS UNDER AGE OF 18
Some of the information you are asked to provide is classified as private under state law. You
have the right to request that some or all of the information not be given to one or both of your
parents/legal guardians. Please complete the form below if you wish to have information
withheld.
Your request does not automatically mean that the information will be withheld. State law
requires the City to determine if honoring the request would be in your best interest. The City is
required to consider:
. Whether you are of sufficient age and maturity to explain the reasons and understand
the consequences;
. Whether denying access may protect you from physical or emotional harm;
. Whether there are reasonable grounds to support your reasons; and
. Whether the data concerns medical, dental, or other health services provided under
Minnesota Statutes Sections 144.341 to 144.347. If so, the data may be released only if
failure to inform the parent would seriously jeopardize your health.
NOTICE GIVEN TO:
DATE:
By:
(name)
(title)
REQUEST TO WITHHOLD INFORMATION
I request that the following information:
Be withheld from:
For these reasons:
Date:
Print Name:
Signature:
DN: 195319 Ver: 4
EXHIBIT 7
CITY OF PRIOR LAKE
DATA PRACTICES ADVISORY
Some or all of the information that you are asked to provide on the attached form is classified
by state law as either private or confidential. Private data is information which generally cannot
be given to the public but can be given to the subject of the data. Confidential data is
information which generally cannot be given to either the public or the subject of the data.
Our purpose and intended use of this information is:
You _ are I _ are not legally required to provide this information.
If you refuse to supply the information, the following may happen:
Other persons or entities who are authorized by law to receive this information are:
DN: 195319 Ver: 4
EXHIBIT 8
CITY OF PRIOR LAKE
SAMPLE CONTRACT PROVISION
Data Practices Compliance. Contractor will have access to data collected or maintained by the
City to the extent necessary to perform Contractor's obligations under this contract. Contractor
agrees to maintain all data obtained from the City in the same manner as the City is required
under the Minnesota Government Data Practices Act, Minn. Stat. Chap. 13 (the "Act").
Contractor will not release or disclose the contents of data classified as not public to any person
except at the written direction of the City. Contractor agrees to defend and indemnify the City
from any claim, liability, damage or loss asserted against the City as a result of Contractor's
failure to comply with the requirements of the Act or this contract. Upon termination of this
contract, Contractor agrees to return data to the City, as requested by the City.
DN: 195319 Vor: 4
APPENDIX A
DATA MAINTAINED BY THE CITY OF PRIOR LAKE
CLASSIFIED AS NOT PUBLIC
Personnel Data (Private)
Minn. Stat. ~ 13.43
All data about an individual who is employed as, or an applicant for employment as, an
undercover law officer is private data.
The following personnel data on current and former employees, applicants for employment,
volunteers, independent contractors, or members or applicants for an advisory board or
commission, are public data:
Name
Employee identification number (which must not be the employee's Social Security
number)
Actual gross salary
Salary range
Contract fees
Bargaining unit
Actual gross pension
Value and nature of employer paid fringe benefits
Basis for and amount of added remuneration, including expense reimbursement
Job title
Job description
Education and training background
Previous work experience
Date of first and last employment
The existence and status (but not nature) of any complaints or charges against the
employee, whether or not resulting in discipline
Final disposition of any disciplinary action, with specific reasons for the action and data
documenting the basis of the action, excluding data that would identify confidential
sources who are employees
Terms of any agreement settling any dispute arising from the employment relationship,
including a "buyout" agreement
Work location
Work telephone number
Badge number
Honors and awards received
Payroll time sheet or other comparable data that are only used to account for
employee's work time for payroll purposes, except to the extent that release of time
sheet data would reveal the employee's reasons for the use of medical leave or other
not publiC data
City and county of residence
Names and home addresses of applicants for appointments to and members of an
advisory board or commission
Financial disclosure statements of elected or appointed officials
ON: 195319 Ver: 4
If it is necessary to protect an employee from harm to self or to protect another person who
may be harmed by the employee, information that is relevant to the safety concerns may be
released to (1) the person who may be harmed or to the person's attorney when relevant to
obtaining a restraining order, (2) a pre-petition screening team in the commitment process, or
(3) a court, law enforcement agency or prosecuting authority.
Applicant Data (Private)
Minn. Stat. ~ 13.43, Subd. 4
Data about current and former applicants for employment or appointment to an advisory board
or commission are private data, except the following information which is public:
Veteran status
Relevant test scores
Rank on eligible list
Job history
Education and training
Work availability
Name, after being certified as eligible for appointment to a vacancy or when considered
a finalist for a position of public employment (which occurs when the person has been
selected to be interviewed by the appointing authority)
Names and addresses of applicants for and members of an advisory board or commission are
public data.
Property Complaint Data (Confidential)
Minn. Stat. ~ 13.44, Subd. 1
The identities of individuals who register complaints concerning violations of state laws or local
ordinances concerning the use of real property are confidential data.
Security Information (Private/Non public)
Minn. Stat. ~ 13.37
Data which if disclosed would be likely to substantially jeopardize the security of information,
possessions, individuals or property against theft, tampering, improper use, attempted escape,
illegal disclosure, trespass, or physical injury. This includes crime prevention block maps and
lists of volunteers who participate in community crime prevention programs and their home
addresses and telephone numbers, but these may be disseminated to other volunteers
participating in crime prevention programs. This also includes interior sketches, photos, or
plans of buildings where detailed information about alarm systems or similar issues could
jeopardize security.
Registered Voter Lists Minn. Stat. ~~ 13.37, 203B.12,
Absentee Ballots (Private/Protected Nonpublic) 201.091
Sealed absentee ballots before opening by an election judge are protected nonpublic
information. Names of voters submitting absentee ballots are private until the close of voting.
Registered voter lists are private, except for use related to elections, political activities, or law
enforcement. The data of birth on voter lists is always private.
ON: 195319Ver: 4
Sealed Bids (Nonpublic)
Minn. Stat. ~ 13.37, Subd. 2
Sealed bids, including the number of bids received, prior to opening, are protected non public
information.
Trade Secret Information (Nonpublic)
Minn. Stat. ~ 13.37, Subd. 1
Government data, including a formula, pattern, compilation, program, device, method,
technique or process (1) that was supplied by the City, (2) that is the subject of efforts by the
City that are reasonable under the circumstances to maintain its secrecy, and (3) that derives
independent economic value, actual or potential, from not being generally known to, and not
being readily ascertainable by proper means by, other persons who can obtain economic value
from its disclosure or use are non public data.
Labor Relations Information
(Nonpublic/Protected Nonpublic)
Minn. Stat. ~ 13.37
Management positions on economic and non-economic items that have not been presented
during the collective bargaining process or interest arbitration, including information collected or
created to prepare the management position are non public data.
Firearms Data (Private)
Minn. Stat. ~ 13.87, Subd. 2
Data about the purchase or transfer of firearms and applications for permits to carry firearms.
Examination Data
Minn. Stat. ~ 13.34
Completed versions of personnel and licensing examinations are private, unless the
Responsible Authority determines that they should be confidential because access would
compromise the objectivity, fairness or integrity of the examination process.
Elected Officials Correspondence (Private)
Minn. Stat. ~ 13.601
Correspondence between individuals and elected officials, but either may make it public.
Federal Contracts Data (Private/Nonpublic)
Minn. Stat. ~ 13.35
To the extent that a federal agency requires it as a condition for contracting with a City, all
government data collected and maintained by the City is classified as private or nonpublic.
ON: 195319 Vor: 4
Civil Investigative Data (Confidential)
Minn. Stat. li 13.39, Subd. 2
Data collected as part of an active investigation undertaken to commence or defend pending
civil litigation, or which are retained in anticipation of pending civil litigation, is confidential,
except that a complainant's statement is private.
Appraisal Data (Confidential/Protected
Nonpublic)
Minn. Stat. li 13.44, Subd. 3
Appraisals made for the purpose of selling or acquiring land through purchase or
condemnation.
Recreational Data (Private)
Minn. Stat. li 13.57
For people enrolling in recreational or other social programs: name, address, telephone
number, any other data that identifies the individual, and any data which describes the health or
medical condition of the individual, family relationships, living arrangements, and opinions as to
the emotional makeup or behavior of an individual.
Law Enforcement Data (Private)
Minn. Stat. ~~ 13.43, 13.80, 13.82,
13.85 and 13.87
See also lili 169.09, 168.10,
169A.70, 171.043, 171.07, 171.071,
171.12, 171.32,243.166,299A.61,
299C.065, 299C.091, 299C.093,
299C.095, 299C.46, 299C.53,
299C.56, 611.272, 626.53, 609.324,
609.3452, 609.3471, 626.556,
626.5563,626.557,626.558,
626.5593,626.89,629.341,
2608.171,2608.198,2608.235,
299C.68, 299F.035, 299F.04,
299F.05, 299F.054, 299F.055,
299F.056, 299F.095, 299F.096
Data collected, created, received or maintained by the police department, sheriff's office or clerk
of court under the Domestic Abuse Act is confidential.
Certain arrest data, request for service data, response or incident data, and written transcripts
of 911 calls (unless it reveals the individual's identity) are public under Minn. Stat. !j13.82.
Otherwise, investigative data collected to prepare a case against a person for the commission
of a crime or civil wrong is confidential or protected non public information while the investigation
is active. Photographs which are part of inactive investigation files are private or nonpublic if
they are clearly offensive to common sensibilities. Booking photographs are public. A law
ON: 195319 Ve,: 4
enforcement agency may temporarily withhold access to a booking photograph if the agency
determines that access will adversely affect an active investigation.
The identity of a victim of child abuse or neglect is private. The identity of a reporter of child
abuse or neglect is confidential. Inactive investigative data which relates to the alleged abuse
or neglect of a child by a person responsible for the child's care is private. Videotapes of child
abuse victims may not be released under any circumstances without a court order.
The following are private:
The identity of undercover law enforcement officers.
The identity of criminal sexual conduct victims.
The identity of certain informants.
The identity of victims or witnesses to a crime whose personal safety or property would
be threatened by disclosure.
The identity of a deceased person whose body was unlawfully removed from a
cemetery.
The identity of a person making a 911 call, or the identity or telephone number of a
service subscriber whose phone is used to place a 911 call, if revealing the person's
identity would threaten his or her personal safety or property or if the objective of the
call was to receive help in a mental health emergency.
The identity of any juvenile in any case, except arrests certified to stand trial as an adult
or in the case of restitution.
Data on registered criminal offenders.
Unique descriptions of stolen, lost, confiscated, or recovered property.
Identities of customers of licensed pawnshops and secondhand goods dealers.
Reward Program Data
(Nonpublic/Confidential)
Minn. Stat. ~ 13.82, Subd. 21
Financial records of a program that pays rewards to informants are protected non public data, or
in the case of individuals, confidential data.
Detention data which would disclose medical, psychological or financial information or endanger
an individual's life is private.
Criminal history data is private, except convictions of crimes which are public data for 15 years
following the discharge of the sentence imposed.
Deliberative processes or investigative techniques are confidential.
Data in arrest warrants or search warrants are confidential until the individual has been taken
into custody, served with a warrant, or appears before the court, except when the law
enforcement agency determines that the public purpose is served by making the information
public.
Human Rights Data (Confidentiall
Protected Nonpublic/Private)
Minn. Stat. ~ 13.552
ON: 195319 Ver: 4
Human rights investigative data are confidential or protected non public data. The name and
address of the charging party and respondent, factual basis of the allegations, and the statute
under which the action is brought are private data.
Planning Survey Data (Private/Nonpublic)
Minn. Stat. ~ 13.59
The following data collected in surveys of individuals conducted for the purposes of planning,
development and redevelopment are classified as private: names and addresses of individuals
and the legal descriptions of property owned by the individuals, and the commercial use of the
properly to the extent disclosure of the use would identify a particular business. In surveys of
businesses conducted for the purposes of planning, development and redevelopment, the
names, addresses, and legal descriptions of business properties and the commercial use of the
property to the extent disclosure of use would identify a particular business is nonpublic.
Lakefront Park Pavilion, Band Shell,
Shelter Rentals (Private/Nonpublic)
Minn. Stat. ~ 13.55
The following data relating to convention rentals are classified as private or nonpublic: Letter or
other documentation from any person who makes inquiry to or who is contacted by the facility
regarding the availability of the facility for staging events, identity of firms and corporations
which contact the facility, type of event which they wish to stage in the facility, suggested terms
of rentals, and responses of City staff to these inquiries, exhibit or data. All rental data is public
information.
City Attorney Records (Confidential)
Minn. Stat. ~ 13.393
The use, collection, storage, and dissemination of data by the city attorney is governed by
statutes, rules, and professional standards concerning discovery, production of documents,
introduction of evidence, and professional responsibility. Data which is the subject of attorney-
client privilege is confidential. Data which is subject of the "work product" privilege is
confidential.
Business Data (Private/Nonpublic)
Minn. Stat. ~ 13.591
The following data that are submitted by a business requesting financial assistance, a license.
or other benefit are private or nonpublic: financial information about the business, including
credit reports; financial statements; net worth calculations; business plans; income and expense
projections; balance sheets; customer lists; income tax returns; and design. market and
feasibility studies not paid for with public funds. This data becomes public when financial
assistance is granted except the following remain private or nonpublic: business plans; income
and expense projections not related to the financial assistance provided; customer lists; income
tax returns; and design, market, and feasibility studies not paid for with public funds.
Proposals (Private/Nonpublic)
Minn. Stat. ~~ 13.591
Proposals submitted in response to a Request for Proposal ("RFP") are private or nonpublic
until the responses are open. Once opened, the name becomes public, but all other data are
private or non public data until completion of the evaluation process. After the process is
completed. all remaining data are public with the exception of trade secret data. If all
responses to an RFP are rejected, see statute for various scenarios.
ON: 195319 Ver: 4
Municipal Obligation Register Data
(Private/Nonpublic)
Minn. Stat. ~ 475.55
Information with respect to the ownership of certain municipal obligations is non public data or
private data on individuals.
Hazardous Materials (Nonpublic)
Minn. Stat. ~ 145.94
Data relating to hazardous substance exposure may be disclosed by the Commissioner of
Health to individuals or the community, including data made nonpublic by law.
Auditing Data (Confidential/Protected
Nonpublic/Private)
Minn. Stat. ~ 13.392
Data, notes and preliminary drafts of audit reports created, collected and maintained by the
internal audit office of the City are protected non public or confidential until the final report has
been published or the audit or investigation is no longer being actively pursued. Data on an
individual supplying information for an audit or investigation that could reasonably be used to
determine the individual's identity are private.
Salary Benefit Survey Data (Nonpublic)
Minn. Stat. ~ 13.435
Salary and personnel benefit survey data purchased from consulting firms or nonprofit
organizations or obtained from employees with written understanding that such data is
nonpublic is nonpublic data.
Social Security Numbers (Private)
Minn. Stat. ~ 13.49
Social Security numbers of individuals are private data, except to the extent access is
specifically authorized by law.
Public Employees Retirement Association
Data (Private)
Minn. Stat. ~ 13.63, Subd. 3
Data on beneficiaries and survivors of members are private: home address, date of birth, direct
deposit account number, and tax withholding data.
Teachers Retirement Association Data
(Private)
Minn. Stat. ~ 13.63, Subd. 2
Data on beneficiaries and survivors of members are private: address, date of birth, direct
deposit account number, and tax withholding data.
ON: 195319 Va,: 4
Electronic Payments, Credit Card
Numbers, Bank Account Numbers
(Nonpublic)
Minn. Stat. ~ 13.6401
Drug and Alcohol Test Results
(Private/Confidential)
Minn. Stat. ~ 181.954
Drug and alcohol test results for public sector employees and job applicants are private data
and cannot be disclosed without written consent of the employee or job applicant.
DN: 195319 Ve" 4
APPENDIX B
CITY OF PRIOR LAKE
FORMS WHICH REQUEST PRIVATE OR CONFIDENTIAL DATA
. General Authorization and Release Pursuant to Minnesota Statutes 13.05, Subd.4,
Minnesota Government Data Practices Act
. Consent for Release of Information
. Employment Application Insert--Important Facts about Information on Your Application
. Notification form and Consent for Controlled Substance and Alcohol Testing for CDL
. State of Minnesota License Application Information
. Minnesota Uniform Firearm Application Receipt Transferee Permit or Report of Transfer
for Firearms
. Parks and Recreation Registration Forms
. Veteran's Preference Points Application
ON: 195319 Ver: 4
POLICE DEPARTMENT
WilLIAM J. O'ROURKE
Chief of Police
Release Type I
General Authorization and Release
Pursuant to Minnesota Statute 13.05, Subd. 4
Minnesota Data Practices Act
TO:
I, , hereby authorize and grant my informed consent to
permit you, , to release to and make available to the
PRIOR LAKE Police Department and/or their agents and/or representatives data classified as private
which concerns me and which may be in your possession. The data which I authorize to be released
consists of private data, as defined by Minn. Stat. 13.02, Subd. 12, and has been collected by you as a
result of my contacts and associations with you and/or your agents and representatives. The information
for which release is authorized includes all data which has been collected, created, received, retained or
disseminated in whatever form which in any way relates to my dealings with you or your agency. I
understand that the purpose of permitting the PRIOR LAKE Police Department to have access to this
information is to determine my suitability for employment with that department. I further understand
that this information may subsequently be utilized for other purposes relating to my possible
employment with the department, including verification of my records and analysis by consultants to the
department who may review my suitability for employment.
This authorization shall be valid for a period of one year, but I reserve the right to, at any time prior to
that expiration, cancel the written authorization by providing written notice to the department or to you
of that fact.
(Signature)
(Date)
16200 Eagle Creek Avenue S.E., Prior Lake, Minnesota 55372 / Ph. (952) 440-3555 / Fax (952) 440-36661
CITY OF PRIOR LAKE
CONSENT FOR RELEASE OF INFORMATION
I,
Print Full Name
(first)
(full middle)
(last)
Residing at
(address)
(city)
(state)
(zip code)
Driver's License/State
Date of Birth
Authorize the Prior Lake Police Department to disclose to the Prior lake City Manager,
Accounting Clerk and the Prior lake City Council all information collected as a result of
the background investigation done for the purpose of evaluating the attached licensed
application.
I understand that failure to provide this release will result in a denial of my application.
I understand that my records are subject to the State Data Practices Act and become
public documents unless otherwise provided for by state or federal law. I also
understand that I may revoke this consent at any time except to the extent that action
has been taken in reliance on it and that in any event, the consent expires automatically
as described below.
This authorization is valid for six (6) months from the date indicated below.
Signature of above individual authorizing release
Witness:
€~E
I '<;.'"
, 'I,'I(NE':>O
CITY OF PRIOR LAKE
16200 EAGLE CREEK AVENUE, PRIOR LAKE, MN 55372
EMPLOYMENT APPLICATION
All persons are welcome 10 apply with the City of Prior Lake. Your application will be considered in competition wilh others for the position in
which you are interested. Please furnish complete information as outlined in this application. Incomplete applications will not be considered.
Read the instructions carefully. All information contained in or connected with this application will be considered for use only in conjunction
with your possible employment with the City of Prior Lake. You may attach any additional information which you believe qualifies you for the
position for which you are applying. The attached materials must supplement the application and not be in lieu of requested data.
POSITION SOUGHT
ANNUAL SALARY DESIRED
TEMPORARY
o
REGULAR
o
PART-TIME
o
FULL-TIME
o
DATE AVAILABLE
PERSONAL INFORMATION
LAST NAME FIRST MIDDLE I SOCIAL SECURITY NUMBER
PRESENT STREET ADDRESS CITY STATE ZIP CODE
DAY TELEPHONE NO, ( ) HOME TELEPHONE NO. ( )
Are you under 18? Yas 0 No 0
Are you willing to work overtime if necessary?
Yes 0 No 0
Yes 0 No 0
Are you a United States citizen OR, if not, do you have permission to work in this country?
EDUCATION AND TRAINING
HOW MANY YEARS OF SCHOOL HAVE YOU COMPLETED? 123456 789101112 13141516 17 181920+
ELEMENTARY HIGH SCHOOL UNDERGRADUATE GRADUATE
':,'ll!!l "":..,,,,,!:,.:!...~ 'Ur "" ., DIPLPMA, DE(3REEORCERTIFICATE MAJpR& MINOR SUBJECTS
High School
College or University
COllege or University
Graduate School
Technical
Technical
List any courses, seminars, workshops, and training programs you completed that might relate to this position.
Course Title
Offered Bv
Completed On
APPLlCDOC
(1998)
EMPLOYMENT HISTORY
Instructions: Beginning with your present or most recent employment or occupation, list all your employers for at least the last five years. Provide complete ...:._"
information. Resumes and additional supporting materials may be submitted in support of but not in lieu of the following.
DATES EMPLOYED (MOIYR)
FROM TO
REASON FOR LEAVING
HOURS WORKED
PER WEEK
PHONE NO.
( )
JOB TITLE
MAY WE CONTACT YES 0 NO 0
IF NOT. WHY?
PRESENT OR LAST EMPLOYER
ADDRESS
SUPERVISOR'S NAME AND TITLE
LAST SALARY
SPECIFIC DUTIES
DATES EMPLOYED (MOIYR)
FROM TO
REASON FOR LEA VI NG
HOURS WORKED
PER WEEK
PHONE NO.
( )
JOB TITLE
LAST SALARY
SPECIFIC DUTIES
DATES EMPLOYED (MOIYR)
FROM TO
REASON FOR LEAVING
HOURS WORKED
PER WEEK
MAY WE CONTACT YES 0 NO 0
IF NOT. WHY?
LAST SALARY
SPECIFIC DUTIES
DATES EMPLOYED (MOIYR)
FROM TO
REASON FOR LEAVING
HOURS WORKED
PER WEEK
PHONE NO.
( )
JOB TITLE
FOURTH LAST EMPLOYER
ADDRESS
SUPERVISOR'S NAME AND TITLE
LAST SALARY
SPECIFIC DUTIES
APPLlC.DOC
(1998)
MILITARY - Complete this section if you served in the U.S. Armed Forces. Also, please complete the separate Veteran's Preference form.
DESCRIBE YOUR DUTIES AND ANY SPECIAL TRAINING BRANCH OF SERVICE
LENGTH OF ACTIVE DUTY
RANK AT DISCHARGE
UNSALARIED AND VOLUNTEER EXPERIENCE (Use additional sheet. if necessary)
VOLUNTEER ORGANIZATION LOCATION
POSiTION HELD IMMEDIATE SUPERVISOR
DUTIES PERFORMED I PHONE NO, ( )
LENGTH OF PARTICIPATION HOURS PER WEEK I SKILLS LEARNED
OFFICE EQUIPMENT/COMPUTER SOFlWARE PROGRAMS
WHAT OFFICE MACHINES DO YOU OPERATE PROFICIENTLY? PHOTOCOPIER D FAX D
DICTATIONfTRANSCRIPTION D 10 KEY ADDING MACHINE D TELEPHONE CONSOLE (PBX) D
DO YOU HAVE EXPERIENCE WITH WORD PROCESSING/SPREADSHEETS? YES D NO D
TYPE OF COMPUTER: IBM/COMPATIBLE D APPLE/MACINTOSH D UNISYS. SWP D OTHER
COMPUTER SOFTWARE YOU USE PROFICIENTLY: MS OFFICE D MS WORD D WORDPERFECT D OTHER
TYPING SPEED TELEPHONE CONSOLE USED
LICENSES
DO YOU NOW HAVE A VALID MINNESOTA DRIVER'S LICENSE? YES D NOD NUMBER
LICENSE CLASSIFICATION: CLASS A D CLASS B D CLASS C D EXPIRATION DATE
OTHER DRIVER'S LICENSES (LIST STATE. CLASS. AND NO.)
iF RELEVANT. LIST OTHER CURRENT PROFESSIONAL REGISTRATIONS, LICENSES OR CERTIFICATES YOU HAVE: INCLUDE DATE FIRST
ISSUED AND EXPIRATION OF CURRENT ISSUANCE:
,ReGISl'RAl'IONS.L1CeNSES;CERl'iFTCATeS.' DATE ISSUED EXPIRAl'lONDATE'
SUPERVISION (Use additional sheet, if necessary)
HAVE YOU EVER SUPERVISED PEOPLE? YES D NO D I FOR WHOM?
CHECK THE FUNCTIONS WHICH YOU HAVE PERFORMED AS A SUPERViSOR.
INTERVIEW CANDiDATE D RECOMMEND FOR HIRE D CONDUCT PERFORMANCE EVALUATION D
DISCIPLINE EMPLOYEE D FIRE EMPLOYEE D COUNSEL EMPLOYEE D
RECOMMEND SALARY D
ESTABLISH OBJECTIVES D
APPLlC.OOC
(1998)
c NAME AND OCCUPATION
REFERENCES Please give the names of three persons (not related to you) who can testify to your character and qualifications.
CONVICTION INFORMATION
No person shall be disqualified from public employment solely or in part because of prior conviction of a crime or crimes, unless the crime or crimes for which
convicted directly relate to the position of employment sought. In determining if a conviction directly relates to the position of public employment sought, the
hiring authority shall consider the requirements of Minnesota Statues, Chapter 356. Final applicants will be subject to a criminal background investigation.
Have you ever been convicted as an adult of a felony, gross misdemeanor or misdemeanor for which a jail sentence can be imposed?
Yes 0 No 0
If yes, dates and name of jurisdiction..
IMPORTANT NOTICE TO ALL APPLICANTS
Minnesota law requires that you be informed of the purposes and
intended uses of the information you provide to the City of Prior Lake
during the application process or during employment.
Any information about yourself that you provide to the City of Prior
Lake during the application and interview process will be used to identify
you as an applicant and to assess your qualifications for employment with
the City. Although you are not legally required to supply informalion. you
are required to provide the information requested in the Employment
Application, if you wish to be considered for employment. If you do not
supply the information requested, your application may not be considered.
The information may be provided to:
1) Persons authorized to have access to the information under state or
federal law; and
2) Persons authorized by court order to have access to the
information; and
3) Persons to whom you consent in writing to have access to the
information.
4) City employees who need to know the information.
Applicant's Signature
AUTHORIZATIONS
I authorize and consent to having city representatives make inquiries
about me if I am to be considered for employment.
Former employers are authorized to give information about me in any
form, oral or written. They are hereby released from all liability for issuing
such information. I hereby knowingly waive any privileges, including
protection under the Data Practices Act, that I have as to such information.
I understand that misrepresentation or omission of facts will be cause
for cancellation of consideration for employment or dismissal jf employed.
J understand that employment may be conditioned upon completion
of a physical examination, completion of testing related to the position and
a Driver's License check. The City requires drug and alcohol testing for
certain positions involved with heavy equipment operations. I agree to
complete applicable tests if I receive a conditional offer of employment.
I understand that this authorization may be revoked in writing by me
at any time and in no event will it be valid for more than one year from the
date below.
Date
My signature confirms that I have read and understand the authorization and notice to applicants set forth above. I recognize that my failure to sign, accurately
complete or falsify information in this application will automatically disqualify me from consideration for employment.
FOR CITY USE. PLEASE DO NOT WRITE BELOW THIS LINE
APPUC.OOC
(l998)
VETERAN'S PREFERENCE POINTS APPLICATION
(THIS FORM MUST BE RETURNED WITH APPLICATION)
ARE YOU APPLYING FOR VETERAN'S BONUS POINTS?
DYES
o NO
"
If you answered "yes," your DD214 or other documentation must be received no later than 7 calendar days after
the application deadline for the position.--
VETERAN'S PREFERENCE POINTS APPLICATION INSTRUCTIONS
Preference points are awarded to qualified veterans and spouses of deceased or disabled veterans to add to their
exam results. Points are awarded subject to the provisions of Minnesota Statutes 43A.11. To be eligible for
veterans preference points you must:
1. be separated under honorable conditions from any branch of the anned forces of the United States 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 Slates or resident alien; or be the surviving spouse of a deceased
veteran (as defined above) or the spouse ofa 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 exclu$ively on I~ngth of
military service.
The infonnation you provide on this fonn will be used to detennine your eligibility for veteran's preference
, , ,
points. You are not required to supply this infonnation, 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 PREFERPNCE POINTS MUST SUPPLY THEIR MARRIAGE CERTIFICATE, THE
VETERAN'S DD214 AND FL-802 OR DEATH CERTIFICATE. .
If you supply the supporting documentation by separate mail, your name and the position applied for must be
included. ' ,
VETERAN'S PREFERENCE POINTS APPLICATION
Veteran If spouse, veteran's name:
Self Spouse
Branch of Service: Period of Active Duty
From: To:
Rank at Discharge: Type of Discharge: Date of Final Service No.:
Discharge:
Are you receiving or eligible for a military Do you have a compensable service-related disability?
pension: Yes No
Yes No
Preference requested: - Veteran - Disabled Veteran
. Spouse of Disabled Veteran Spouse of Deceased Veteran
Your Preference Points application cannot be considered without supporting documentation (see instructions
above). If the documentation is not attached, it must be received in our office no later than 7 calendar days after
the application deadline for the position in order to guarantee points are awarded in a timely manner.
Supporting documentation: _ is attached
will be submitted within 7 days of application
deadline
FOR OFFICE USE ONLY
5 points
10 points
D....;.....!ln,<;/QI;
PRIOR LAKE PARKS &
RECREATION
ADULT ACTIVITIES
For FALL
MARK YOUR CALENDARS - SENIOR SOCIAL FALL SCHEDULE
DATES: Thursdays, September 25, October 23, November 20 & December 18 Time: 1 :30-3:30 p.m.
LOCATION: Lakefront Park Pavilion, 5000 Kop Parkway
Stans Museum. Danoerfield's & Murphy's Landino Tour (331401)
DATE: Wednesday, September 17 FEE: $12 resident/$17 non-resident TIME: 9:30a.m.-3:00 p.m.
LOCATION: Bus will pick-up and drop-off at Prior Manor and at the Municipal Parking Lot located off
of Colorado Street.
REGISTRATION DEADLINE: Wednesday, September 10
At the Stans Museum we will be given a guided tour of the Stans historic home, museum and the lovely gift shop.
Next is on to Dangerfield's for a delicious lunch on vour own. The special "Library Room" has been reserved for
our group and you will be able to choose from the regular menu. Finally we will visit Murphy's Landing for a stroll
through historic homes. We will fmish the tour at Murphy's Landing with a piece of old-fashioned pie and piping
hot coffee (Included in Trip fee) in the main historic building on site.
Tour of Prior Lake - Great for new residentsl (331405)
DATE: Wednesday, October I FEE: FREE TIME: 5:45-8:00 P.M. Bus will leave at 6 p.m.!
LOCATION: Meet at Lakefront Park, 5000 Kop Parkway
REGISTRATION DEADLINE: Wednesday, September 24
Join City Manager Frank Boyles and other special guests on a beautiful tour ofthe City of Prior Lake. We will
show points of interest including City Hall, library, post office, parks, schools, the downtown area and more. We
will also take time to tour the fire station and maintenance center. Learn about new developments, existing
neighborhoods, parks, trails and streets in our developing community. Space is limited so register early.
Senior Trip to Treasure Island Casino (331402)
DATE: Friday, October 17 FEE: $20 resident/$25 non-resident TIME: 9:00 a.m.-6:00 p.m
LOCATION: Bus will pick-up and drop-off at Prior Manor and the Municipal Parking Lot located off of
Colorado Street.
REGISTRATION DEADLINE: Friday, October 3
The trip includes a ride along the Mississippi River enjoying lunch (croissant sandwich, potato salad, potato chips,
jumbo chocolate chip cookie, and beverage) on Treasure Island's new passenger cruise ship, Spirit of the Water.
Then you will be able to try your luck at Treasure Island's 2400 slot machines, 64 blackjack tables, pull-tabs, and of
course bingo. Come along for this fun filled day, where everyone is a winner!
Halloween BOOoie
DATE: Wednesday, October 22 FEE: $5/person - $7/person before Noon on 10/22 or at the door.
Tickets will be available at Prior Lake Recreation Department.
TIME: 6:00-9:00 p.m
LOCATION: Rosemount Banquet Facility, 13885 S. Robert Trail, Rosemount, MN.
Frighteningly good music by the Paul Heffron Trio will have you BOOging the night away. Devilish desserts fill
the tables and cash bar available if you dare. Costumes are encouraged, but not required. TransDortation on vour
!!.!!!!!. Pre-recorded information Line: 952-985-1780 or Community Center: 651-322-6000.
OVER-+
Fall Wellness Workshop (331403)
DATE: Wednesday, November 5 TIME: 1:00 p.m
FEE: $5/person - $7/person at the door.
LOCATION: Rosemount Community Center, 13885 S. Robert Trail, Rosemount, MN.
Am-aging Grace" Maturing with Wisdom and Humor: will feature Mary Ann Glasgow, a psychotherapist and
professional speaker as she presents a new concept of "age". "Annie" as she is known, will present a broadened
lIefmition of humor and an approach to handling gracefully the stress of "aging", Join us for this fabulous new
program on wellness and aging. A combined effort afsenior programs in Dakota County, we will present wellness
information on a variety of topics, in a variety of settings. Watch for Wellness Wisdom quarterly. Refreshments
will be served. TransDortatlon on vour own. Pre-recorded information Line: 952-985-1780 or Community
Center: 651-322-6000.
"Out of Order" - Old Loa Theatre (331404)
DATE: Thursday, November 13 FEE: $27-resident/$32-non-resident TIME: 10:30 a.m. - 3:45 p.m.
LOCATION: Bus will pick-up and drop-off at Prior Manor and at the Municipal Parking Lot located off
of Colorado Street.
REGISTRATION DEADLINE: Thursday, November 6
After a delicious lunch, (included in the fee) we will enjoy the fast paced British farce about a Conservative Member
of parliament who plans to spend the evening with a secretary of the leader of the opposition party in a top London
hotel. Things go disastrously wrong when they discover a body in their hotel room.
Please make checks payable to: CITY OF PRIOR LAKE and RETURN to Prior Lake Parks & Recreation, t6200 Eagle
Creek Avenue S.E., Prior Lake, MN 55372. If you have any questions, please call the Parks and Recreation at 447-4230 or
447-9820. Programs requiring registration must be paid for in advance.
...............................................................................
Participant's Name:
Address:
Phone:
City/State/Zip:
Resident
Non-Resident_
TOTAL:
$
PARTICIPANT WAIVER: In consideration of your accepting this entry, I hereby, myself and my heirs, waiver any and all rights and claims
for any and all injuries from whatever cause suffered by the above participant in the indicated activities. All information contained or connected
with this registration form will be considered personal and confidential and will be used only in conjunction with the registration process for
programs sponsored by the City of Prior Lake.
SIGNATURE:
Data Privacv Act
In accordance with the Minnesota Government Data Practices Act, the Recreation Department hereby informs you that the personal information
we are requesting of you and/or your child or guardian on our registration form is now considered private. Private data is available to you and to
the City staff who need to have this information to perform their duties, but not to the public. While you may choose to withhold this data, the
consequences could be that the City's Recreation staff may not be able to complete your registration and/or you may not receive updated program
information, such as scheduled changes.
· Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is
required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax
Identification number and the Social Security number of each license applicant.
Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are
required to advise you of the following regarding the use of this information:
I. This infonnation may be used to deny the issuance, renewal, or transfer of your license in the
event you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest:
2. Upon receiving this infonnation, the licensing authority will supply it only to the Minnesota
Department of Revenue. However, under the Federal Exchange ofInfonnation Agreement
the Department of Revenue may supply this infonnation to the Intemal Revenue Service:
3. Failure to supply this infonnation may jeopardize or delay the processing of your licensing
issuance or renewal application.
Please supply the following infonnation and retum along with your application to the agency issuing the
license, DO NOT RETURN TO THE DEPARTMENT OF REVENUE.
LICENSE BEING APPLIED FOR OR RENEWED:
LICENSING AUTHORITY:
(Name of City, County or State Agency issuing license)
LICENSE RENEWAL DATE:
Applicant's Name:
Applicant's Home Address:
Social Security Number
Business Name:
Business Address:
Minnesota Tax Identification Number:
Federal Tax Identification Number'
Signature, Position (Officer, Partner, Etc.) Date:
SPCl. DOC
To: Sandy Stahl
Department of Human Services
Residential Program Management Division
Human Services Building
444 Lafayette Rd
51. Paul, MN 55155.3826
Regarding: Gun Permit Applicant Data Release Form
Full Name: DOB:
Also known as:_(any alias names)
Maiden Name:
I hereby authorize and grant by informed consent to permit the Minnesota Department of
Human Services to release to and make available to the PRIOR LAKE POLICE and/or
its agents and/or representatives data classified as private which concems me and which
may be in your possession. The data which I authorize to be released consists of private
data as defined by Minnesota Statute 13.02, Subd. 12, and has been collected by you as a
result of my contact and associations with you, and/or your agents and representatives.
The information for which release is authorized includes all data which has been
collected, created, received, retained or disseminated in whatever form which in any way
related to my dealing with you or your agency. This information includes, but is not
limited to, data regarding mental illness or chemical dependency.
I understand that access to this information is to determine my eligibility for a Permit to
Purchase a Handgun.
This authorization shall be valid for a period of one year but I reserve the right to, at any
time prior to that expiration, cancel the written authorization by providing written notice
to the PRIOR LAKE POLICE DEPARTMENT or to you ofthat fact.
Signature (full name)
Date
Expiration Date of Release
440-3555. Prior Lake Police
(Agency Contact Person/Telephone Number)
R:\Fonns\Gunperm.doc
MINNESOTA UNIFORM FIREARM APPLICATION/RECEIPT
B ~~:~~::~ (TYPE OR PRINT ONL Y) DD NEW
D CARRY HANDGUN RENEWAL
NOTICE TO APPLICANT: An incomplete application will be denied. In the event an applicant is found 10 have knowingly falsified this application, or omitted
pertinent information, that person may be subject to criminal prosecution. The permit to carry shall be void at the time that the holder becomes prohibited from possessing a pistol under
section 624.713, in which event the holder shall return the pennit within five (5) days to the application authority. The waiting period will begin on the date that this application is submitted.
This application ;s valid only with a recent 1" x 1" color head-and-shoulder photograph of the applicant attached. (Photograph required only for permit to carry)
NOTICE TO LICENSED DEALER: This form must be completed in its entirety or it will be denied. The section marked Dealer Information must be completed in addition to the applicant
information. This application must be delivered to the law enforcement agency having jurisdiction within three (3) days or it will not be considered.
DEALER NAME (BUSINESS NAME):
FF LICENSE NUMBER:
DEALER STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
APPLICANTS IDENTITY VERIFIED BY PICTURE ID:
DYES DNO
DATE OF AGREEMENT TO TRANSFER: SIGNATURE OF DEALER REPRESENTATIVE
The Minnesota Data Practices Act requires that you be advised of the following information:
As an applicant for a permit to purchase a firearm, for reporting the transfer of a firearm, or permit to carry a handgun, you are being asked to provide private and/or confidential data
about yourself which will be used to check criminal histories, arrest records, and warrant infonn8tion to determine your eligibility to possess a firearm and/or carry a handgun.
You may refuse to provide this information; however, should you refuse, the investigation cannot be completed and will result in your application not being processed. Information
regarding ''previous residence addresses (past 10 years)" is optional. However, if provided, it will reduce the possibility of-error regarding older records. The information that you provide
will be used by the licensing agency to complete its investigation, and may be conveyed to other law enforcement agencies.
I HAVE READ AND UNDERSTAND THE ABOVE DATA PRACTICES ADVISORY.
SIGNATURE:
As an applicant for a permit to purchase a firearm, reporting the transfer of a firearm, or for a permit to cany a handgun, you are being asked to authorize the release of commitment
information maintained by the Commissioner of Human Services which will be used to determine your eligibility to possess a firearm and/or carry a handgun. You may refuse to provide
this authorization; however, should you refuse, the investigation cannot be completed and will result in your application not being processed.
I, (type or print your name) ___~_~___________________~____________________________~~_ authorize the Commissioner of Human
Services to disclose commitment information to the extent the information relates to my eligibility to possess a handgun or semiautomatic military-style assault weapon under Minnesota
Statute ~624.713, subdivision 1 to the local pblice authority reviewing this application for the purpose of conducting the background investigation required by Minnesota Law.
SIGNATURE:
DATE:
NOTE: This consent Is SUbJect to revocation at any time except to the extent that the Commissioner of Human Services has already taken action In reliance on It.
ff not previously revoked, thIs authorization will tennlnate upon notfflcatlon to the applicant 01 the denial or grant 01 this application.
NAME (LAST, FIRST, MIDDLE, JR/SR):
DATE OF BIRTH:
HOME PHONE NUMBER:
MAIDEN NAME (IF APPLICABLE) OR OTHER NAMES YOU HAVE USED:
PRESENT RESIDENCE ADDRESS:
CITY:
COUNTY:
ZIP CODE:
RACE
HEIGHT:
WEIGHT:
EYE COLOR:
HAIR COLOR:
MN DRIVERS LICENSE OR ID NUMBER:
DISTINGUISHING PHYSICAL CHARACTERISTICS (INCLUDING SCARS, MARKS, TATTOOS, ETC):
NATURE OF EMPLOYMENT/OCCUPATION OR PERSONAL SAFETY HAZARD REQUIRING CARRYING OF A HANDGUN: (REQUIRED ONLY FOR PERMIT TO CARRY)
DATE
STREET ADDRESS
CITY
COUNTY
STATE
ZIP CODE
1.' Have-you been convicled of a crime of violence as defined in Minn. Stat. ~ 624.712 in Minnesota or elsewhere and not
either (1) been restored to your civil rights at least 10 years ago or (2) your sentence expired at least 10 years ago? ............. 0 NO 0 YES
If yes, complete the following information:
CONVICTION OATE(S): I CRIME(S):
LOCATION OF CONVICTION (CITY, COUNTY, STATE):
2. Have you been convicted after August 1, 1992, of assault in the fifth degree under Minn. Stat. 9 609.224 or of domestic
assault under Minn. Stat. ~ 609.2242? ..........................,........,........................,........................,....,.........................................0 NO 0 YES
If yes, was the assault committed within three years of a previous assault conviction under Minn. Stat. 9 609.221 to
9609.224 OR was the assaull victim a family or household member? ............,.......................................................,.............. 0 NO 0 YES
If yes, complete the following information:
CONVICTION DATE(S): I CRIME(S):
LOCATION OF CONVICrlON (CITY, COUNTY, STATE):
3. Have you been convicted of a crime punishable by imprisonment for a term exceeding one year regardless of what
punishment was actually imposed? .......,..........................,',........................................,.............."..".................,............,........ 0 NO 0 YES
If yes, complete the following information:
CONVICTION OATE(S): I CRIME(S):
LOCATION OF CONVICTION (CITY, COUNTY. STATE):
4. Have you ever been pardoned for a crime of violence? ........................................................................................................... 0 NO 0 YES
If yes, complete the following information:
PARDON DATE: I ORIGINAL CHARGE:
LOCATION OF ORIGINAL CONVICTION (CITY, COUNTY, STATE):
,
Under the law of the jurisdiction where you were convicted, has your conviction been expunged, set aside, pardoned, or
have you had your civil rights restored? ,...,..,........................ ..,...........,.............".........."................., .,.................................,. 0 NO 0 YES
(Attach a copy of documentation establishing that the conviction has been expunged, set aside, pardoned or that you
have had your civil lights restored,)
5, Have you ever been convicted for lhe unlawful use, possession, or sale of a controlled substance (other than conviction for
possession of a small amount of marijuana as defined in Minn. Stat. ~ 152.01, subd. 16)? ..................................................... 0 NO 0 YES
6. Are you an unlawful user of any controlled substance as defined in Chapter 152, Minnesota Slatutes? .................................. 0 NO 0 YES
7. Have you ever been hospitalized or committed for treatment for the habitual use of a controlled substance or marijuana? ..,.. 0 NO 0 YES
If yes, attach proof that you have not abused a controlled substance or marijuana during the previous two years,
8. Have you ever been confined or committed to a lreatment facility in Minnesota or elsewhere as "chemically dependenf' as
defined in Minn. Stat. ~ 2538,02? ...............".......................",.,.......................................,...................,..............................",. 0 NO 0 YES
If yes, have you completed lrealment? "".............., .., .."""........................", ,.".........., ".......................,............................"..... 0 NO 0 YES
9. Do you hold a firearms safety certificate? (If yes, attach copy thereof) (Required only for permit to carry) ............................... 0 NO 0 YES
10. Have you satisfactorily completed a practical test of your ability to use and care for firearms as approved by this law
enforcement agency? (If yes, attach proof of completion) (F!equired only for permit to carry) .............................,.................. 0 NO 0 YES
11. Have you fled from any stale to avoid prosecution for a crime or to avoid giving testimony in any criminal proceedings? ........ 0 NO 0 YES
Revised 05198
Page 2
12: Are yo'lJ a peace officer? ............................................................................................,............................................................ 0 NO 0 YES
If yes, have you ever been informally admitted to a treatment facility pursuant to Minnesota Statute 9 2538.04 for
chemical dependency? ..........................,................................",.,.,.,.................................",.,............,...............,.. .................. 0 NO 0 YES
If yes, attach certificate from head of the facility discharging or provisionally discharging you from the facility.
13. Have you ever been committed to a treatment facility in Minnesota or elsewhere as a "mentally ill," "menIally retarded,"
or "mentally ill and dangerous to the public" person as defined in Minnesola Statute 9 2538,02? ............,............................... 0 NO 0 YES
If yes, attach proof you are no longer suffering from this disability.
14. Have you been confined in a treatment facility as a "mentally ill," "mentally retarded," or "mentally ill and dangerous to the
public" person as defined in Minnesota Statutes 9 2538.02 or been found incompetent to stand trial or not guilty by reason
of mental illness? ........................,.............,.." ,...........................................,.........................................",........................" ,..... 0 NO 0 YES
15. Have you ever served in the anned forces of the United States? .......................,.....................................,..,........................... 0 NO 0 YES
16, Have you ever been discharged from the armed forces of the United States under dishonorable conditions? ......................... 0 NO 0 YES
17, Have you ever renounced your citizenship having been a citizen of the United States? .................,...........................,............ 0 NO 0 YES
18. I am (check one). . . . . . . . . . . . . . . . . . . . . . . . . . , . . ..D American Citizen 0 Legal Resident 0 Allen (Attach copy of documentation)
19. Are you subject to a court order that restrains you from harassing, stalking, or threatening an intimate partner, the child
of an Intimate partner, or your own child? ..........,....,...................................,.............................................,............................. 0 NO 0 YES
If yes, attach copy of court order ........,................,... ..",..........................",......................,.......................................................
20. Have you been convicted in any court of a misdemeanor crime of domestic violence? ....,...................................................... 0 NO 0 YES
If yes, complete the following information:
CONVICTION DATE(S),
CAIME(S),
LOCATION OF CONVICTION (CITY, COUNTY, STATE):
SIGNATURE OF APPLICANT:
The fOllowing restrictions apply to the possession of firearms, to transferee permits, reports of transfer for handguns and semiautomatic
military-style assault weapons, and permits to carry handguns.
. Must be at least 18 years old to acquire or possess a handgun or semiautomatic military-style assault weapons, bul under federai law must be at
least 21 years old to acquire handguns from licensed dealers.
. Must not have been convicted of a crime of violence (as defined in Minnesota Statutes 9 624.712, subdivision 5) in Minnesota or elsewhere unless
10 years have elapsed since your civil rights have been restored or your sentence has expired, and during that time you have not been convicted
of any other crime of violence.
. Must not have been convicted of fifth-degree assault as defined in Minnesota Statutes 9 609,224 or domestic assault as defined in Minnesota
Statutes 9 609.2242 in Minnesota or elsewhere since Augusl1 , 1992: (1) within 3 years of a previous assault conviction under Minnesota Statutes
9 609.221 to 9 609.224; or (2) where the assault victim was a family or household member, unless 3 years have elapsed since the date of
conviction and during that time you have not been convicted of any other fifth-degree or domestic assault.
. Must not have been judicially committed to a treatment facility in Minnesota or elsewhere as "mentally ill," "mentally retarded," or "mentally ill and
dangerous to the public."
Revised 05/98
Page 3
. Must not have been either convicted in Minnesota or elsewhere of unlawful use, possession or sale of a controlled substance (other than
possession of a small amount of marijuana), or hospitalized or committed for treatment for the habitual use of a controlled substance or marijuana,
unless you possess a certificate from a medical doctor or psychiatrist, or other satisfactory proof, that you have not abused a controlled substance
during the past two years.
Must not have been confined or committed to a treatment facility in Minnesota or elsewhere as chemically dependent, unless you have completed
treatment.
. Must not be a peace officer who has been informally admitted to a treatmenl facility for chemical dependency, unless you possess a certificate
from the head of the lreatment facility discharging or provisionally discharging you from that facility.
. Must not have been convicted in Minnesota or elsewhere of a crime punishable by imprisonment for more than a year (other than offenses
pertaining to antitrust violations, unfair trade praclices, restraints of trade, or similar offenses relating to the regulation of business practices)
unless your civil rights have been restored or the conviction has been pardoned, expunged, or set aside,
. Must not be a fugitive from justice.
Must not be a user of any controlled subslance as defined in Chapter 152 of Minn, Stalutes.
. Must not be an alien who is illegally or unlawfully in lhe United States.
. Must not have been discharged from the armed forces of the United States under dishonorable conditions.
. Must not have renounced your United States citizenship.
. Must not have been confined to a treatment facility in Minnesota or elsewhere as "mentally ill," "mentally retarded," or "mentally ill and dangerous
to the public" or found incompetent to sland lrial or not guilty by reason of mental illness unless you possess a certificate from a medical doctor or
psychiatrisllicensed In Minnesota, or other satisfactory proof lhal you no longer suffer from this disability,
Must not be subject to a court order that (1) was issued after a hearing of which you had actual notice and at which you had an opportunity to
participate; (2) restrains you from harassing, stalking, or threatening an intimate partner, a child of an igtimate partner, or your own child, or
engaging in other conduct thaI would place an intimate partner in reasonable fear of bodily injury to that person or a child; and (3) includes a
finding that you represent a credible threat to the physical safety of such intimate partner or child or by its terms explicitly prohibits the use,
attempted use, or lhreatened use of physical force against such Intimate partner or child that would reasonably be expected to cause bodily injury,
. Must not have been convicted in any court of a misdemeanor crime of domestic violence as meant by 18 United States Code section 922(g)(9).
The following requirements, in addition to those stated above, also apply to permits to carry handguns:
. Must provide either a firearms safety certificate recognized by the Department of Natural Resources, evidence of successful completion of a lesl
of ability to use a firearm supelVised by the chief of police, or sheriff, or other satisfactory proof of ability to use a pistol safely.
. Must have an occupation or personal safety hazard requiring a permit to carry.
Revised 05/98
Page 4
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