2/13/2019 1 STATE OF MINNESOTA DISTRICT COURT COUNTY OF HENNEPIN FOURTH JUDICIAL DISTRICT COMMISSIONER APPLICATION FORM Real Estate Broker Certified Appraiser Licensed Attorney Other Name: Business/Firm Affiliation: Preferred Address: Preferred Phone: Fax: What County do you reside in How did you learn about this opportunity? Please list and attach a copy of current professional licenses, registrations or certificates related to this job including the applicable license/registration number(s): Please provide any relevant information, that you believe qualifies you to serve as a Condemnation Commissioner (e.g. education, training, certificates, licenses, work experiences, etc.). You may attach a resume. Hennepin County District Court fosters an inclusive, multicultural environment that values diversity and relationships. Briefly describe your professional experience related to working with people of various backgrounds (i.e., race, color, religion, sex, or national origin). Please limit your response to a maximum of 100 words. You may attach an additional response if needed. American LegalNet, Inc. www.FormsWorkFlow.com 2/13/2019 2 COMMISSIONER APPLICATION FORM For internal use only We invite applicants to voluntarily self-identify their gender, race or ethnicity. You are not obligated to complete these fields and any information you provide will be treated confidentially. The data will be retained as required by federal law and will not be used for or have any effect on any decision. 1. Gender? Female Male Other I prefer not to identify 2. With which race/ethnicity do you identify yourself? American Indian/Alaska Native (Not Hispanic or Latino) Asian (Not Hispanic or Latino) Black or African American (Not Hispanic or Latino) Hispanic or Latino Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) White (Not Hispanic or Latino) Two or More Races (Not Hispanic or Latino) I prefer not to identify I declare that any statement in this application or information provided is true and complete and hereby acknowledge that I have read and understand the information below. Date: Signature (Do not print) The state has the right to verify information provided in this application. False information may subject an applicant to the penalty provisions of M.S. 24743A.39. In connection with this application for employment, I authorize the State of Minnesota and any agent acting on its behalf to conduct an inquiry into any job-related information contained in this application, including, but not limited to, my records maintained by an educational institution relating to academic performance such as transcripts. Moreover, I hereby release the State of Minnesota and any agent acting on its behalf from all liability of whatsoever nature by reason of requesting such information from any person. Please submit application to: Hennepin County District Court Administration Attn: Kellie Van Slyke C-3 Government Center (MC 332) 300 South Sixth Street Minneapolis MN 55487-0332 612/348-3542 (kellie.vanslyke@courts.state.mn.us) American LegalNet, Inc. www.FormsWorkFlow.com