APPLICATION FOR EMPLOYMENT
CITY OF ADRIAN
(An Equal Opportunity Employer)
(PLEASE PRINT)
______________________________________________________________________________________
Last Name First Name Middle Name
Social Security Number:____________________________ Phone No.:_____________________________
Present Address:_________________________________________________________________________
Length of Time at this Address:_____________________________________________________________
How Long Do You Expect to Live in this Area? _________________________________________________
Position(s) Applied For: ___________________________________________________________________
Rate of Pay Desired: _____________________________________________________________________
When Can You Start? ______________________ Anticipated Ending Date: _______________________
Are You 18 Years of Age or Older? __________________________________________________________
Have you ever been convicted of a crime, including any alcohol-related traffic crimes?_________________
If so, when, where and nature of offense? ____________________________________________________
______________________________________________________________________________________
Person to be notified in case of accident or emergency:
Name: ___________________________________ Phone Number: ______________________________
Address: ______________________________________________________________________________
Do you have a valid Michigan Driver’s License? _______ If yes, Driver’s License No.:__________________
Do you have a valid Driver’s License from another State? ________
If yes, identify the State and Driver’s License Number? __________________________________________
Have you previously filed an Employment Application with the City of Adrian? _______ If so, when?______
Have you ever been dismissed from or asked to resign from any employment position? Yes_____ No_____
If yes, explain:__________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PERSONAL REFERENCES
(Not Former Employers or Relatives)
NAME AND OCCUPATION ADDRESS PHONE #
STREET WORK #
CITY HOME #
STATE ZIP
STREET WORK #
CITY HOME #
STATE ZIP
STREET WORK #
CITY HOME #
STATE ZIP
List any Friends or Relatives working for the City of Adrian: ______________________________________
List below your present and past employment,
beginning with your most recent employer.
DATE(Mo & Yr.) EMPLOYER
NAME & ADDRESS
(Type of Business)
LAST
SALARY
REASON FOR
LEAVING
NAME OF
SUPERVISOR
From _____To_____
_____________________
_____________________
_____________________
Describe the Work
You Did:
From _____To_____
_____________________
_____________________
_____________________
Describe the Work
You Did:
From _____To_____
_____________________
_____________________
_____________________
Describe the Work
You Did:
Are there any other experiences, skills or qualifications which you feel would especially qualify you for work with the City of
Adrian? (Applicants are invited to submit resumes or other pertinent information in written form.)_________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
In your own handwriting please comment upon your abilities, and why you wish to work for the City of Adrian. ______________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
RECORD OF EDUCATION
(Include current course of study or training)
Name, City & State of
Educational Institution
Years
Attended?
Graduated?
High School:
From: To: Yes
No
Extracurricular activities:
Offices, Honors, Awards:
Name, City & State of
Years
Attended
Graduated?
If No Degree
Credits Earned
Type of Degree
Received/Expected
MO YR
Major/Sem Hrs.
Minor/Sem Hrs.
Overall
Grade Pt.
College or University:
From: To:
Yes
No
From: To:
Yes
No
From: To:
Yes
No
Extracurricular Activities:
Offices, Honors:
MILITARY SERVICE RECORD
Were you in the U.S. Armed Forces? ________ If yes, what branch? ___________________________________
Date of Duty: From: Mo_____Day_____Year______ to Mo_____Day______Year_______
Rank at Discharge___________________ Type of Discharge_________________________________________
List Duties in the Service. Include Special Training: ________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
CERTIFICATIONS
Lifeguarding Expiration Date _______________________
CPR for Professional Rescuer Expiration Date _______________________
Community CPR Expiration Date _______________________
Food Handler Card Expiration Date _______________________
Other (Please list):
______________________ Expiration Date ______________________
______________________ Expiration Date ______________________
PLEASE READ AND SIGN BELOW
I certify the facts set forth in this application of employment and in my resume are true and
complete.
I hereby authorize the City of Adrian (Hereinafter referred to as “The City”) to contact all my former
and current employers, educational institutions, military entities, and other references I have
provided regarding me and my performance record and work, academic and/or military experience.
I also hereby release The City and its employees, city commission, elected officials and agents, and
all of my former and current employers, educational institutions, military entities, and the other
references I have provided, from any and all liability and damages for releasing or using information
concerning me and my performance record and work, academic and/or military experience. I also
hereby waive any right under the Bullard-Plawecki Right to Know Act, 1978, PA 397, to receive
written notice from The City or any former or current employer, that disciplinary reports, letters of
reprimand, or other disciplinary action taken against me while employed, will be or have been
disclosed to a third person or entity.
I agree not to commence any action or suit relating to my employment with The City more than 30
days after the date of termination of such employment, and to waive any statute of limitations to
the contrary.
If I am employed, I understand that additional personal data will be required for determination of
benefit eligibility and for statistical purposes.
I will abide by all policies, rules and regulations of the City of Adrian.
_____________________________________ ___________________
Signature Date
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