Election Of Veteran'S Preference Form - City Of Medina printable pdf download

Revised 1/8/2007

Election of Veteran’s Preference Form

(Minnesota Statute 43A.11)

Name: __________________________________________

(Please Print)

Are you eligible to claim veteran’s preference?

____Yes

____No (if “no” is marked, please stop here)

Do you wish to claim veteran’s preference if you achieve a passing score?

____Yes

____No

If yes, please check the preference you are claiming:

___ Veteran – defined as a U.S. citizen or resident alien who separated under honorable

conditions, and

1. has served on active duty for at least 181 consecutive days, or

2. was discharged by reason of disability incurred while on active duty, or

3. has met active duty requirements as defined by the Code of Federal Regulations, or

4. has active military service certified under section 401, Public Law Number 95-202

In addition, you cannot be currently receiving a monthly veteran’s pension based exclusively

on length of service. Attach a copy of your DD214 in order to receive 5 points.

___ Disabled Veteran – defined as a veteran having a compensable service connected disability

as adjudicated by the U.S. Veterans Administration or the retirement board of one of the

branches of the Armed Forces, which disability is currently existing. (Attach a copy of

your DD214 and FL 802 (or an equivalent letter from a service retirement board) to

receive 10 points.

___ Spouse of a deceased veteran. Attach a copy of your marriage certificate, the veteran’s

DD214 and the death certificate to receive 5 points.

___ Spouse of a disabled veteran who is unable to use preference due to disability. Attach a copy

of your marriage certificate, the veteran’s DD214 and FL802 (or an equivalent letter from

a service retirement board) to receive 10 points.

AFFIDAVIT:

I hereby claim veteran’s preference for this vacancy and certify that all the information given is

true, complete, and the best of my knowledge.

I hereby authorize the Veteran’s Administration to release information necessary to process this

application to the City of Medina.

SIGNATURE:_____________________________________ DATE:_______________

Election Of Veteran'S Preference Form - City Of Medina