Application For Provisional Status Form - State Board Of Assessors Page 6
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9MINNESOTA
STATE BOARD OF ASSESSORS
APPLICATION FOR CERTIFIED MINNESOTA ASSESSOR
IMPORTANT: Print or Type ABOVE the Line. ALL sections of this application MUST be completed or it will be returned
to you for completion.
Personal Data:
Collection of data relating to gender, date of birth and residency is required by MN Statute 214.07 (i)
_____________________
____________________
_____
________
__________________
Last Name
First Name
MI
License #
Date of Birth (M/D/Y)
_________________________ _________________ ____ _______
Home Address (Street and Number)
City
State
Zip Code
Gender: ___Male ___Female
______________________
(___) _____________
(___) _____________
___________________
County of Residence
Home Phone
Work Phone
E-mail Address
Have you ever been convicted of a felony? ___ No ___Yes (If Yes, supply details on separate sheet of paper and attach)
Where should the Board send correspondence? ___Home
___Office (Supply address if different from above)
EDUCATION
School Name
Location
Dates Attended
Graduate/Degree
________________
________________
_______________
____________
High School
________________
________________
_______________
____________
Business or Trade School (attach copy of transcript)
________________
________________
_______________
____________
College or University (attach copy of transcript)
ASSESSMENT AND APPRAISAL COURSES
Name of Course
Sponsored by
Dates Attended
(1) ________________________________
______________________
___________
(2) ________________________________
______________________
___________
(3) ________________________________
______________________
___________
(4) ________________________________
______________________
___________
(5) ________________________________
______________________
___________
(6) ________________________________
______________________
___________
ASSESSMENT EXPERIENCE
Most Recent Employer
______________________________ _____________________
________________
____________
Name of Employer (Jurisdiction)
Title of Position
Date(s) of Employment Full or Part Time?
____________________________________
______________________ (
) _____________________
Supervisor’s Signature
Date
Phone Number
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