Fillable Printable COUNTY OF MONROE EMPLOYMENT APPLICATION

COUNTY OF MONROE EMPLOYMENT APPLICATION

COUNTY OF MONROE

EMPLOYMENTAPPLICATION

125 East Second Street

Monroe, Michigan 48161

(734) 240-7295 FAX (734) 240-7266

NAME: TODAY’S DATE:

CURRENTADDRESS:

E-MAILADDRESS

HOME PHONE: WORK PHONE: Social Security Number

Application Instructions:

If you need help to ll out this application form or for any phase of the employment process, please notify the person that gave you this form and every effort

will be made to accommodate your needs in a reasonable amount of time.

1. Please read “APPLICANT NOTE.”

2. Complete entire form.

3. If more space is needed to complete any question, use comments section.

4. Print clearly; incomplete or illegible applications will not be processed.

5. Do not ll out any other attached forms unless instructed.

APPLICANT NOTE:

This application form is intended for use in evaluating your qualications for employment. This is not an employment contract.

Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this

form are grounds for terminating the applicant process or, if discovered after employment, terminating employment. All qualied

applicants will receive considerations without discriminations because of sex, marital status, race, age, creed, national origin or

the presence of disabilities. Afelony conviction will not necessarily bar an applicant from employment. Afrmative action hiring

may be requested by qualied applicants. Additional testing of job - related skills and for the presence of drugs in your body may

be required prior to employment. After an offer of employment, and prior to reporting to work, you are required to submit to a

medical review. Depending on county policy and the needs of the job, you will be required to complete a medical history form

and be required to be examined by a medical professional designated by the county.

AVAILABILITY

For which position are you applying? ______________________________________________

On what date can you start? _________________What category do you prefer? Full Time Part Time Temporary

For which schedules are you available? Weekdays Weekends Evenings Nights Overtime Shift Other

NAME _________________________________________POSITION_______________________________________DATE__________________

Last First M.I.

Street City State Zip Code

EDUCATIONPlease enter the highest grade completed. __________

NAME CITY/STATE DATES GRADUATED DEGREE TYPE

SECURITYList states and countries of residence for the past seven years___________________________________________________

__________________________________________________________________________________________

Yes No Have you used any names or Social Security Numbers other that those on this page? If so, please explain in comment section below.

Yes No Have you been convicted of a felony and/or served time in the past seven years? If so, please describe below. (In accordance with county policy this

information will be reviewed for job relatedness and time since last conviction.)

INCIDENTCITY/STATE CHARGE

JOB-RELATED SKILLSNOTE: Do not ll out any part of this section you believe to be non-job related.

List any languages in which you are uent

__________________________________________________________________________

Yes No If the job requires, do you have the appropriate valid driver’s license?

DL# ______________________Type _________________State of Issue ________________________________

Yes No Have you had any moving violations? Please Describe________________________________________________

Please list any other skills, licenses or certicates that may be job related or that you feel would be of value to this job or county._____

____________________________________________________________________________________________________________

Yes No Have you been given a job description or had the requirements of the job explained to you?

Yes No Do you understand these requirements?

Yes No Can you perform the requirements of this job with or without reasonable accommodations?

SPECIAL SKILLS AND ABILITIES:

Do you type?

Yes No Words per minute ________________Can you take shorthand? Yes No Words per minute.

COMMENTS: ________________________________________________________________________________________________

____________________________________________________________________________________________________________

EMPLOYMENT REFERENCES

Your application will not be considered unless every question in this section is answered. Since we will make

every effort to contact previous employers, the correct telephone numbers of past employers are critical.

MOST RECENT EMPLOYER

Yes No Are you currently working for this employer?

Yes No If yes, may we contact them? PHONE NUMBER

_______________________________________________________ ________________________________________ _________________________

COMPANY NAMECITYSTATE

FROM _______________TO______________________________________________________________________________________________

DATES EMPLOYEDJOB TITLESUPERVISOR’S NAME

__________________________________________________________________________________________________________________________________

DUTIES

___________________PER ____________________________________________________________________________________________________

SALARY(HOUR, WEEK, MONTH)REASON FOR LEAVING

SECOND MOST RECENT EMPLOYER

Yes No Are you currently working for this employer?

Yes No If yes, may we contact them? PHONE NUMBER

_______________________________________________________ ________________________________________ _________________________

COMPANY NAME

CITYSTATE

FROM

_______________TO______________________________________________________________________________________________

DATES EMPLOYEDJOB TITLESUPERVISOR’S NAME

__________________________________________________________________________________________________________________________________

DUTIES

___________________PER ____________________________________________________________________________________________________

SALARY(HOUR, WEEK, MONTH)REASON FOR LEAVING

THIRD MOST RECENT EMPLOYER

Yes No Are you currently working for this employer?

Yes No If yes, may we contact them? PHONE NUMBER

_______________________________________________________ ________________________________________ _________________________

COMPANY NAMECITYSTATE

FROM _______________TO______________________________________________________________________________________________

DATES EMPLOYEDJOB TITLESUPERVISOR’S NAME

__________________________________________________________________________________________________________________________________

DUTIES

___________________PER ____________________________________________________________________________________________________

SALARY(HOUR, WEEK, MONTH)REASON FOR LEAVING

REFERENCES

Included only individuals familiar with your work ability. Do not include relatives.

NAME ADDRESS/PHONE YEARS KNOWN/RELATIONSHIP

CERTIFICATIONS AND RELEASE

I certify that I have read and understand the applicant note on page one of this form and that the answers given by

me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge

and belief. I understand that any false information, omissions or misrepresentations of facts called for in this

application may result in rejection of my application or discharge at any time during my employment. I authorize

the county, and/or its agents, including consumer reporting bureaus, to verify any of this information including,

but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies

and law enforcement authorities to release any information concerning my background and hereby release any

said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever

for issuing this information provided, however that this release does not prohibit the ling of a charge with the

Equal Employment Opportunity Commission based on the release of such information. I also understand that the

use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug

testing to detect the use of illegal drugs prior to and during employment.

________________________________________________

_____________________

Signature Date

MONROE COUNTY EQUAL OPPORTUNITY SURVEY

Some ofthe following information isrequested,not for employment decisions, butfor record keeping in compliance

with federal laws and guidelines. Some of the information is requested is also for purposes of aiding the County

in its voluntary afrmative action efforts.

This form is kept separate from employment application and will be kept condential. You do not have to ll this

form out and refusing to do so will not subject you to adverse treatment.

Thefederallaws and guidelines concerningthis subject are: a) Uniform GuidelinesonEmployee Selection

Procedures of 1978; b) Sections 503 and 504 of the Rehabilitation Act of 1973; c) The Vietnam Era Veterans

Readjustment Assistance Act of 1974; and d) Michigan Public act 220 of 1976.

Social Security No. - - Date: ________________

Print Name: _______________________________________________________________________________

Last First Middle Initial

Please check appropriate boxes below:

How did you nd out about this job? Check below:

Job Announcement Just walked into Human Resources Ofce

Newspaper Ad Group Organization

Which Newspaper? _____________________ Which one? ____________________________

County Employee Other

Michigan Employment Security Commission _Explain:_______________________________

______________________________________