Fillable 67 PITTSFIELD CHARTER TOWNSHIP

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67 PITTSFIELD CHARTER TOWNSHIP

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  • 31 check-boxes
  • 132 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Pittsfield Charter Township

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1
PITTSFIELD CHARTER TOWNSHIP
APPLICATION FOR EMPLOYMENT
(AN EQUAL OPPORTUNITY EMPLOYER)
Return to:
Department
6201 W. Michigan Avenue
Ann Arbor, MI 48108
Failure to complete application in its entirety may result in the rejection of your application.
INSTRUCTIONS:
Please print the requested information in the spaces provided below.
Date of Application: _________________________ Date available to begin work: _________________________
PERSONAL INFORMATION
Are you legally eligible for employment in the U.S.?* Yes ____ No ____
Police/Fire applicants only – Are you a U.S. citizen? Yes ____ No ____
Are you 18 years or older? Yes ____ No____
If related to anyone in our employ, state name and relationship to you.___________________________________________
* Pittsfield Charter Township conforms to the Immigration Reform and Control Act of 1986 which requires you to
furnish
documentation showing your identity and legal authorization to work in the United States once you have been offered
employment.
Street Address
City, State, Zip Code
Home Telephone Number
( )
Alternate Telephone Number
( )
Last Name First
Middle
Email Address
2
EMPLOYMENT DESIRED
POSITION(S) APPLIED FOR:
_______________________________________
_______________________________________
_______________________________________
PAY/SALARY DESIRED: ___________________________
Kind of work sought? Full Time ____ Part Time ____ Seasonal ____ Other ____
If part time or seasonal, please specify days, hours or time of year sought: ________________________________________
Have you ever worked for another governmental entity? Yes ____ No
____
If YES, reason for leaving:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
EDUCATION
Applicants for certain positions may be required to provide transcripts.
What language
s, other than English, do you speak, read, or write? (Please check)
( ) ( ) ( )
Language Speak Read Write Level of Fluency
( ) ( ) ( )
Language Speak Read Write Level of Fluency
Education Name and Location of School
No. of Years
Completed
Course of
Study
Earned
High School
College/University
Vocational/Trade/
Graduate School
3
GENERAL
Do you have any special training, skills, qualifications, licences, certifications, or other experiences that relate to the
position(s) applied for?
________________________________________
____________________________________________________________
____________________________________________________________________________________________________
Although a valid Michigan driver’s license is required for all Pittsfield Charter Township jobs, exceptions are made
for certain non-driving jobs if the applicant, who is otherwise qualified for a position for which he/she applies, requires and
requests it.
Type of license: Standard Driver's License ____ Chauffeur’s License ____ Commercial Driver’s License (CDL) ____
License number: _______________________________________
Endorsements: ____________________ Expiration Date: ____________ Current Number of Points: ________
(A driving record check will be conducted for applicants for positions requiring a current driver’s license.)
Police Applicants Only (provide copies):
Are you certified or have you completed the Michigan Commission on Law Enforcement Standards (MCOLES) basic
police training to be a certified law enforcement officer in the State of Michigan?
Written Yes ____ No ____ Date Completed _______________________
Physical Yes ____ No ____ Date Completed _______________________
Have you completed an MCOLES approved police academy?
Name of academy ____________________________________ Date Completed______________________
Out-of-State Applicants (provide copies):
Have you completed the MCOLES Recognition of Prior Training and Experience Program? Yes ____ No ____
Date Completed _______________
U.S. Military Service:
Branch of Service _______________________________ From _______________ To _______________
Ra
nk or Rating __________________________________ Type of Discharge ___________________________
EMPLOYMENT INFORMATION
Have you ever been discharged or requested to resign any job? Yes ____ No ____
If YES, please explain circumstances:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Are you presently employed? Yes ____ No ____
4
EMPLOYMENT HISTORY
Please give an accurate, complete, full-time and part-time employment record. Start with current, or most recent employer.
(List additional employers on a separate sheet, if necessary). This section must be completed fully, even if a resume is
attached. Please print all information.
1
Company Name
Address City/State Zip Code
Supervisor
Telephone
( )
Employed (List Month and Year)
From: To:
Salary Starting: Ending:
Reason for Leaving:
List Your Job Title and Responsibilities
2
Company Name
Address City/State Zip Code
List Your Job Title and Responsibilities
Supervisor
Telephone
( )
Employed (List Month and Year)
From: To:
Salary Starting: Ending:
Reason for Leaving:
3
Company Name
Address City/State Zip Code
List Your Job Title and Responsibilities
Supervisor
Telephone
( )
Employed (List Month and Year)
From: To:
Salary Starting: Ending:
Reason for Leaving:
4
Company Name
Address City/State Zip Code
List Your Job Title and Responsibilities
Supervisor
Telephone
( )
Employed (List Month and Year)
From: To:
Salary Starting: Ending:
Reason for Leaving:
5
EMPLOYMENT HISTORY (CONTINUED)
PHYSICAL RECORD
We may contact the employers
listed on the previous page
unless you indicate those you
do not want us to contact.
Employer
Name
Email Address
Telephone
Occupation
Years
Known
In case of emergency, notify:
________________________________________________________________________________________________
Name Address Telephone Number
________________________________________________________________________________________________
Medical Examinations. In accordance
with applicable legal requirements, Pittsfield Charter Township may require job
applicants to undergo a medical examination after an offer of employment has been made and prior to the
commencement of employment duties, and may condition the offer of employment on the results of such examination.
________________________________________________________________________________________________
I HEREBY CERTIFY THAT I AM NOT CURRENTLY ENGAGED IN THE ILLEGAL USE OF DRUGS. I understand
that as a condition of employment, I may be required to take a pre-employment drug test for the illegal use of drugs
which may include the collection of urine samples from my person. I agree that the results of this test may be submitted
to Pittsfield Charter Township or its authorized representative, and I expressly release the collection agency and the
testing laboratory from any and all liability for performing the requested test, and for communicating the results to the
Township. I understand that if the results of any pre-employment drug test are positive, it will be cause for rejection of
my application or, if I am hired, that my employment with the Township may be immediately terminated.
Applicant’s Signature ___________________________________
REFERENCES
DO NOT CONTACT
Reason
Please list three professional/work references, not related to you, whom you have known for over a year.
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6
SIGNATURE
(Read Carefully Before Signing)
Please return to: Pittsfield Charter Township
Human Resources Department
6201 W. Michigan Avenue
Ann Arbor, MI 48108
• I certify that the answers and information given by me in this application are true, correct and complete without
qualification. I understand that Pittsfield Charter Township has the right to refuse to hire or immediately
discharge me, at any time, if it discovers that I have provided incomplete, untrue, or misleading answers or
information in this application or on any other documents or forms submitted at any time during my
employment.
• I hereby a
uthorize Pittsfield Charter Township to verify the answers and information given by me in this
application and to make any investigation on my background deemed necessary. I authorize former employers,
law enforcement organizations, educational institutions, and any other third party contacted by the Township to
release to the Township any information they have regarding me without providing written notice to me.
• I authorize Pittsfield Charter Tow
nship to use any information in its possession concerning me for any purpose
it deems appropriate, including disclosure of information to any third party, future employer or prospective
future employer without notification to me of such disclosure, and I release the Township from any liability in
connection with such use or disclosure.
• If I am hired by Pittsfield Charter Township, I understand and agree that I will be bound by the r
ules,
regulations, policies, procedures, and other terms and conditions of employment of the Township, as they are
from time-to-time changed, with or without notice.
• If I am hired by Pittsfield Charter Township, I understand that I have the right to terminate my employment at
any time and for any reason, with or without notice. I further understand that, except as set forth in any
collective bargaining agreement, the Township can terminate the employment relationship at any ti
me for any
lawful reason, with or without cause, with or without notice. This employment relationship exists regardless of
any other written statements or policies or any other Township document or any verbal statements to the
contrary. No one except the Township Supervisor can enter into any kind of employment relationship or
agreement which is contrary to the above. To be enforceable, any
employment relationship or agreement which
is contrary to the above must be in writing and personally signed by the Township Supervisor, and be attested
by the Township Clerk.
• I agree not to commence any action or claim relating to my employment with Pittsfield Charter Township or
this application for employment more than six (6) months after the date of the challenged action or this
application, and to waive any statute of limitations to the co
ntrary.
Applicant’s Signature ___________________________________________ Date ___________________________
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67 PITTSFIELD CHARTER TOWNSHIP

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Completed 15 July 2020

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