APPLICATION FOR EMPLOYMENT (PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER)

DATE

Date

Name

First NameLast Name

DL#

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

HOME PHONE NUMBER

CELL PHONE NUMBER

Email

example@example.com

ARE YOU EIGHTEEN YRS. OR OLDER?

YesNo

ARE YOU A CITIZEN OF THE U.S.?

YESNO

DO YOU USE ANY TOBACCO PRODUCTS?

YESNO

IF SO, HOW OFTEN?

DO YOU ENGAGE IN THE USE OF ILLEGAL DRUGS?

YESNO

DATE YOU CAN START

Date

SALARY DESIRED

ARE YOU ABLE TO PERFORM THE FUNCTIONS OF THAT POSITION?

ARE YOU ABLE TO MEET THE ATTENDANCE REQUIREMENTS FOR THE POSITION?

WHAT HOURS ARE YOU AVAILABLE TO RESPOND TO EMERGENCY CALLS?

CAN YOU ATTEND SEASONAL AND FIREFIGHTER TRAINING TWO OR THREE TIMES PER MONTH?

HAVE YOU BEEN A MEMBER OF A FIRE DEPARTMENT BEFORE?

IF SO, WHERE? WHAT IS THE CHIEF'S NAME AND NUMBER?

DO YOU HAVE FIRST AID TRAINING?

DATE LAST CERTIFIED?

Date

TYPE OF FIRST AID TRAINING?

EVER APPLIED TO BE A MEMBER OF THE FIRE DEPARTMENT BEFORE?

WHEN?

REFERRED BY

EDUCATION

	NAME/LOCATION OF SCHOOL	NUMBER OF YEARS ATTENDED	DID YOU GRADUATE?	SUBJECTS STUDIED
GRADE SCHOOL
HIGH SCHOOL
COLLEGE
TRADE, BUSINESS, OR CORRESPONDENCE SCHOOL

GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK

SPECIAL SKILLS

CIVIC OR ATHLETIC OR SIMILAR ACTIVITIES (exclude any organizations which would divulge the religion, race, color, national origin,

CIVIC OR ATHLETIC OR SIMILAR ACTIVITES

exclue any organizations which would divulge the religion, race, color, national origin, age, sex, height, weight, familial staus, marital status, or other protected classification of its members

U.S MILITARY OR NAVAL SERVICE DATES

Date

RANK

PRESENT MEMBERSHIP IN NATIONAL GUARD OR RESERVES?

YESNO

DO YOU HAVE TRUCK DRIVING EXPERIENCE?

IF SO, TYPE OF VEHICLE?

DRIVER’S LICENSE CERTIFICATION?

WHY DO YOU WANT TO BE A FIREFIGHTER?

FORMER EMPLOYERS (LIST BELOW LAST THREE EMPLOYERS, STARTING WITH LAST OR CURRENT ONE FIRST)

DATE MONTH & YEAR

	NAME/ADDRESS OF EMPLOYER	SALARY	POSITION	REASON FOR LEAVING	NAME OF SUPERVISOR	EMPLOYMENT DATES
TO
TO
TO
TO

MAY LAKETOWN TOWNSHIP OR THE FIRE DEPARTMENT CONTACT THESE EMPLOYERS

YESNO

WHICH OF THESE JOBS DID YOU LIKE THE BEST?

WHAT DID YOU LIKE MOST ABOUT THIS JOB?

REFERENCES: GIVE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST 1 YEAR.

	Name	Address and Phone Number	Business or Relationship	Years Aquainted
1.
2.
3.

Signature Of Applicant

AS PART OF MY EMPLOYMENT APPLICATION FILED WITH LAKETOWN TOWNSHIP, DATED AS BELOW I HAVE LISTED FORMER AND/OR CURRENT EMPLOYERS, AS WELL AS ONE OR MORE ADDITIONAL REFERENCES. I AUTHORIZE EACH FORMER OR CURRENT EMPLOYER AND EACH ADDITIONAL REFERENCE TO COMMUNICATE DIRECTLY WITH LAKETOWN TOWNSHIP OR THE FIRE DEPARTMENT RELATIVE TO MY EMPLOYMENT RECORD AND ANY OTHER RELEVANT INFORMATION WHICH WOULD OR COULD HAVE A BEARING ON MY ABILITY OR INABILITY TO ADEQUATELY PERFORM FOR LAKETOWN TOWNSHIP THE JOB FOR WHICH I HAVE APPLIED. I SPECIFICALLY WAIVE ANY RIGHT I HAVE UNDER SECTION 6 OF MICHIGAN PUBLIC ACT 397 OF 1978, AS NOW OR SUBSEQUENTLY AMENDED (THE "BULLARD- PLAWECKI EMPLOYEE RIGHT TO KNOW ACT"), TO RECEIVE WRITTEN NOTICE IF A CURRENT OR FORMER EMPLOYER DIVULGES A DISCIPLINARY REPORT, LETTER OF REPRIMAND, OR OTHER DISCIPLINARY ACTION TO LAKETOWN TOWNSHIP OR THE FIRE DEPARTMENT. I FURTHER CONSENT TO LAKETOWN TOWNSHIP OR THE FIRE DEPARTMENT CONDUCTING A CRIMINAL CONVICTION RECORD CHECK, A DRIVING RECORD CHECK, AND A SEX OFFENDER REGISTRY CHECK.

Date

I AUTHORIZE THE RELEASE OF SUCH RECORDS DISCLOSED BY ANY SUCH CHECKS.

YESNO

IN CASE OF EMERGENCY NOTIFY:

NAME

ADDRESS

PHONE NO.

READ CAREFULLY:

I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS OF THIS APPLICATION. MY QUESTIONS CONCERNING THE APPLICATION, IF ANY, HAVE BEEN ASKED AND ANSWERED TO MY SATISFACTION.

I CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THIS APPLICATION IS TRUE AND COMPLETE. I UNDERSTAND THAT IF ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS ARE DISCOVERED, MY APPLICATION MAY BE REJECTED AND, IF I AM EMPLOYED, MY EMPLOYMENT MAY BE TERMINATED. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO COMFORM TO THE TOWNSHIP’S POLICIES AND PROCEDURES.

I UNDERSTAND THAT IF I AM NOT SELECTED FOR EMPLOYMENT WITH LAKETOWN TOWNSHIP FOR THE FIRE DEPARTMENT, CERTAIN STATE OR FEDERAL LAWS MAY CREATE ONE OR MORE CAUSES OF ACTION FOR ME, IF THE REFUSAL TO HIRE ME WAS FOR ONE OR MORE ILLEGAL REASONS. I UNDERSTAND THAT IF I WISH TO PURSUE ANY OF MY RIGHTS UNDER ANY OF THESE STATE OR FEDERAL STATUTES, I MUST FILE ANY CAUSE OF ACTION WITH THE APPROPRIATE STATE OR FEDERAL COURT OR STATE OR FEDERAL AGENCY WITHIN NINE MONTHS OF THE DATE OF THIS APPLICATION FOR EMPLOYMENT.

I UNDERSTAND THAT ANY EMPLOYMENT WITH LAKETOWN TOWNSHIP FOR THE FIRE DEPARTMENT IS AT WILL, MEANING IT IS TERMINABLE WITH OR WITHOUT NOTICE AND WITH OR WITHOUT CAUSE AT ANY TIME BY EITHER LAKETOWN TOWNSHIP FOR THE FIRE DEPARTMENT OR THE EMPLOYEE.

DATE

Date

Signature

LAKETOWN TOWNSHIP FOR GRAAFSCHAP FIRE DEPARTMENT APPLICATION FOR EMPLOYMENT (PRE-EMPLOYMENT QUESTIONNAIRE) (AN EQUAL OPPORTUNITY EMPLOYER)

Employment Desired