HAMBURG TOWNSHIP

Application for Employment

P. O. Box 157 Hamburg, Michigan 48139 810-***-**** Education

High School/College

(List last attended first)

Address Years Attended/Course

Studied

Degree Received

Military Service From To

Additional Skills/Training/Licenses Not Listed Above From To Hamburg Township is committed to EOE in all our personnel practices and prohibits discrimination on grounds of race, color, religion, sex, national origin, age, or physical or mental handicap. Information provided by you on this application form, will be used solely for purposes of assessing your qualifications for potential employment.

Name (Last) (First) (Middle) Social Security Number Address (Street) (City) (State) (Zip) Home Telephone Number Are you at least 18 years old? Daytime Telephone Number: Type of position desired: Date available for work: Salary Expected:

$

Do you have a valid Michigan Driver’s License? License Number: Employment History

Provide the following information for your current and past employers, assignments or volunteer activities, starting with the most recent. (Use additional sheets if necessary.) Explain any gaps in employment in the comments section below. Employer Address (Street) (City) (State) (Zip)

Supervisor’s Name & Title Your Position Work Phone Number Employment Dates Reason for Leaving

From: To:

Describe Your Duties: Employer Address (Street) (City) (State) (Zip)

Supervisor’s Name & Title Your Position Work Phone Number Employment Dates Reason for Leaving

From: To:

Describe Your Duties: Employer Address (Street) (City) (State) (Zip)

Supervisor’s Name & Title Your Position Work Phone Number Employment Dates Reason for Leaving

From: To:

Describe Your Duties: Employer Address (Street) (City) (State) (Zip)

Supervisor’s Name & Title Your Position Work Phone Number Employment Dates Reason for Leaving

From: To:

Describe Your Duties: Comments (Including explanation of any employment gaps): References

Give the names of at least three business/work references, who are not related to you and are not previous supervisors whom we may contact. If not applicable, list three school or personal references who are not related to you. Organization Offices Held

List any additional information you would like us to consider: Have you ever been convicted of a crime? If so, when, where and nature of offense? Convictions will not necessarily disqualify you from employment but will be considered in relation to the position for which you are applying.

Are there any felony charges pending against you? If yes, please explain. Name Address (Street) (City) (State) (Zip)

Occupation Daytime Phone Number Relationship & Years Known Name Address (Street) (City) (State) (Zip)

Occupation Daytime Phone Number Relationship & Years Known Name Address (Street) (City) (State) (Zip)

Occupation Daytime Phone Number Relationship & Years Known Additional Information

List professional, trade, business, or civic associations and any offices held. Exclude memberships which would reveal sex, race, religion, national origin, age, color, disability or any other similarly protected status. I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for denying employment or immediate discharge from the employer’s service, whenever it is discovered. I understand it is the Township’s policy to adhere to all provisions of the ADA and the Rehabilitation Act of 1973.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

Signature of Applicant Date / /

HAMBURG TOWNSHIP

P. O. Box 157

Hamburg, Michigan 48139

810-***-****

Authorization and Understanding

Upon the signing of the Authorization and Understanding, I represent that all of the information now or hereafter given by me in support of my application for employment is true and complete. I authorize you to verify any of the information concerning my employment, education, training, credentials, driver’s license, and criminal history with the appropriate individuals, companies, institutions, or agencies. I authorize them to release such information as you require, including my prior disciplinary employment record. I hereby release you and them from any liability whatsoever as a result of such inquiries and disclosures.

I agree that any false information in support of my application may subject me to dismissal at any time during the period of my employment. In the event of an offer of employment, I understand that I may be required to take a drug screen test.

In the event of employment, I agree I shall be bound by the rules, policies, and regulations of Hamburg Township, Livingston County, and the State of Michigan.

In the event of employment, I authorize Hamburg Township to release such information as a prospective employer may require, including my prior disciplinary employment record. I hereby release you and them from any liability whatsoever as a result of such inquiries and disclosures.

Signature Date

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