STATE OF MINNESOTA
STATE OF MINNESOTA DISTRICT COURT
COUNTY OF HENNEPIN FOURTH JUDICIAL DISTRICT
COMMISSIONER APPLICATION FORM
Real Estate Broker Certified Appraiser Registered Attorney
Name: ____________________________________________________________________________________
Firm Name: _______________________________________________________________________________
Home Address: _____________________________________________________________________________
Business Address: __________________________________________________________________________
Home Phone: ____________________________ Work Phone: ___________________________________
Please list current professional licenses, registrations or certificates related to this job and list the type and license/registration number(s):
____________________________________________________________________________________________________________________________________________________________________________________
Professional Affiliations/Partnerships: __________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Judicial Appointments as Commissioner (List case name, file number and judge under whom appointed):
____________________________________________________________________________________________________________________________________________________________________________________
Professional Experience: _____________________________________________________________________
__________________________________________________________________________________________
Are you a Hennepin County resident? Yes No
Do you own real estate in Hennepin County? Yes No
If you answered YES to owning real estate in Hennepin County, please list: _____________________________
____________________________________________________________________________________________________________________________________________________________________________________
Educational Background (Name of college, university, technical, professional, business, etc. and the degree achieved):
____________________________________________________________________________________________________________________________________________________________________________________
Government Positions Held (past and present): ______________________________________________________
__________________________________________________________________________________________
COMMISSIONER APPLICATION FORM
CONFIDENTIAL/OPTIONAL INFORMATION
(Available to Appointing Judge Only)
Name: ________________________________ Social Security Number: ___________________________
Affiliated Financial Institutions: _______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Clients: ___________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Please list three character references (non-related) that specifically apply to this position:
Name Address City/State/Zip Telephone_______________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I declare that any state 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. §43A.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: Patty Botes
MC 332 Government Center
300 South Sixth Street
Minneapolis MN 55487-0332
612/348-6739
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