APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

Charter= Township of Ironwood

= N10892 = Lake Road, Ironwood, MI <= st1:PostalCode w:st=3D"on">49938

(906) 932-5800

Fax (906) 932-5089

The Charter<= /st1:PlaceName> Township of Ironwoo= d does not discriminate on the basis of race, color, national origin, sex,

religion, age, or disabilit= y in employment or provision of services, programs or activities.

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PERSONAL INFORMATION:

NAME &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; SOCIAL SECURITY NO.

STREET = ; &nbs= p; &= nbsp; = ; &n= bsp; = ; &n= bsp; = ; HOME TELEPHONE NO.

CITY &nbs= p; &= nbsp; &nbs= p; &= nbsp; = ; &n= bsp; = ; DRIVERS LICENSE NO.

STATE &nbs= p; &= nbsp; ZIP = ; &nbs= p; &= nbsp; CELL PHONE OR DAY PHONE NO. &nbs= p; &= nbsp;

&nbs= p;

EDUCATION= : &= nbsp; &nbs= p; &= nbsp; &nbs= p; FROM TO = DEGREE/MAJOR

HIGH SCHOOL

COLLEGE &nbs= p;

OTHER &nbs= p;

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SPECIAL S= KILLS OR TRAINING:

<= /p>

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EMPLOYMENT HISTORY (BEGIN WITH MOST RECENT)

FROM &nbs= p; TO

JOB TITLE

<= /p>

EMPLOYER AND ADDR= ESS

<= /p>

DUTIES

NAME OF SUPERVISO= R AND TELEPHONE

ANNUAL SALARY/WAG= ES

REASON FOR LEAVIN= G

MAY WE CONTACT EM= PLOYER/SUPERVISOR? [ ] YES &nbs= p; [ ] NO

<= /span>

PAGE 1 OF 4 PAGES

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EMPLOYMENT HISTORY (CONTINUED)

FROM &nbs= p; TO

JOB TITLE

EMPLOYER AND ADDR= ESS

DUTIES &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; = ;

NAME OF SUPERVISO= R AND TELEPHONE

ANNUAL SALARY/WAG= ES

REASON FOR LEAVIN= G

MAY WE CONTACT EM= PLOYER/SUPERVISOR? [ ] YES &nbs= p; [ ] NO

<= /span>

FROM &nbs= p; TO

JOB TITLE

EMPLOYER AND ADDR= ESS

DUTIES &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; = ;

NAME OF SUPERVISO= R AND TELEPHONE

ANNUAL SALARY/WAG= ES

REASON FOR LEAVIN= G

MAY WE CONTACT EM= PLOYER/SUPERVISOR? [ ] YES &nbs= p; [ ] NO

<= /span>

FROM &nbs= p; TO

JOB TITLE

EMPLOYER AND ADDR= ESS

DUTIES &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; = ;

NAME OF SUPERVISO= R AND TELEPHONE

ANNUAL SALARY/WAG= ES

REASON FOR LEAVIN= G

MAY WE CONTACT EM= PLOYER/SUPERVISOR? [ ] YES [ ] NO

<= /span>

FROM &nbs= p; TO

JOB TITLE

EMPLOYER AND ADDR= ESS

DUTIES &nbs= p; &= nbsp; &nbs= p;

NAME OF SUPERVISO= R AND TELEPHONE

ANNUAL SALARY/WAG= ES

REASON FOR LEAVIN= G

MAY WE CONTACT EM= PLOYER/SUPERVISOR? [ ] YES &nbs= p; [ ] NO

PAGE 2 OF 4 PAGES

MILITARY = SERVICE &= nbsp;

BRANCH OF MO/YR SERVED &nbs= p; ACTIVE DUTY HIGHEST = ; SKILL SPECIALTY

SERVICE = ; FROM TO &n= bsp; = ; OR RESERVE? GRADE = ; OR PRIMARY DUTY

LIST SPECIAL SCHO= OLS ATTENDED/SKILLS ACQUIRED DURING MILITARY SERVICE

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REFERENCE= S (AVOID USING MEMBE= RS OF THE CLERGY)

NAME = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; = ;

ADDRESS = ; &n= bsp; = ; &n= bsp; = ;

POSITION/TITLE/PR= OFESSION

TELEPHONE

APPROXIMATELY HOW M= ANY YEARS HAS THIS INDIVIDUAL KNOWN YOU?

NAME = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; = ;

ADDRESS = ; &n= bsp; = ; &n= bsp; = ;

POSITION/TITLE/PR= OFESSION

TELEPHONE

APPROXIMATELY HOW M= ANY YEARS HAS THIS INDIVIDUAL KNOWN YOU?

NAME = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; = ;

ADDRESS = ; &n= bsp; = ; &n= bsp; = ;

POSITION/TITLE/PR= OFESSION

TELEPHONE

APPROXIMATELY HOW M= ANY YEARS HAS THIS INDIVIDUAL KNOWN YOU?

NAME = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; = ; = ;

ADDRESS = ; &n= bsp; = ; &n= bsp; = ;

POSITION/TITLE/PR= OFESSION

TELEPHONE

APPROXIMATELY HOW M= ANY YEARS HAS THIS INDIVIDUAL KNOWN YOU?

PAGE 3 OF 4 PAGES

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ADDITIONAL INFORMATION

POSITION APPLIED = FOR

EMPLOYMENT DESIRE= D &nbs= p; [ ] FULL-TIME &nbs= p; [ ] PART-TIME &nbs= p; [ ] TEMPORARY

ARE YOU NOW OR WE= RE YOU EVER EMPLOYED BY THIS TOWNSHIP? &nbs= p; [ ] YES [<= span style=3D'mso-spacerun:yes'> ] NO

IF YES, WHAT POSI= TION?

FROM TO REASON FOR LEAVING:

LIST ANY RELATIVES EMPLOYED BY OR CURRENTLY HOLDING AN APPOINTIVE OR ELECTIVE POSITION AT THE TOWNSHIP:

HAVE YOU EVER BEEN CONVICTED OF A FELONY? = [ ] YES [ ] NO

HAVE YOU RECEIVED= ANY TRAFFIC CITATIONS IN THE LAST 5 YEARS?&n= bsp; [ ] YES [ ] NO

IF YES, PLEASE AT= TACH A SEPARATE SHEET GIVING FULL INFORMATION

IS THERE ANY OTHER INFORMATION, APPLICABLE TO THIS POSITION, YOU WISH TO HAVE CONSIDERED AS = PART OF YOUR APPLICATION FOR EMPLOYMENT?

APPLICANT PLEASE READ CAREFULLY AND SIGN BELOW

INFORMATION PROVI= DED AND STATEMENTS MADE BY ME IN THIS APPLICATION ARE, TO THE BEST OF MY=

KNOWLEDGE, COMPLE= TE AND TRUE.

I UNDERSTAND THAT= IF I AM EMPLOYED BY THE TOWNSHIP, THIS INFORMATION PROVIDED OR FALSE STATEMENTS MADE AS PART OF THIS APPLICATION MAY BE CONSIDERED AS CAUSE FOR DISMISSAL= .

APPLICANT SIGNATU= RE

_________________= __________________________________________________________________________<= o:p>

DATE OF APPLICATI= ON

_________________= __________________________________________________________________________<= o:p>

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DATE APPLICATION RECEIVED

REVIEWED BY &nb= sp; = &nb= sp; = DATE

COMMENTS:

PAGE 4 OF 4 PAGES

AUTHORIZATION & RELEASE

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NAME: ______________________________________________________________<= /span>

please print

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ADDRESS<= span class=3DGramE>:____________________________________________________= ________

street address= city state zip code

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hereby authorizes the Charter Township of Ironwoo= d or its agents or representatives to solicit any information, credit history, = or opinions, verbal or written, pertaining to the undersigned.

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This authorization and release shall be effective for all of the following pers= ons or agencies, but this list shall not be inclusive as the intent of this re= lease is to allow the Charter Township of Ironwood in complete freedom in conduc= ting an investigation into the undersigned for purposes of potential employment= of the undersigned with the Charter Township of Ironwood. The non-inclusive l= ist of persons or organizations who may respond to this authorization is as follows:

1. Any law enforcement agency.

2. Any Local, State or Federal governmental agency.

3. U.S= . Armed Forces.

4. Any educational institution.

5. Any past or present employer of the undersigned.

6. Any financial institution or credit reporting bureaus.

7. Any other person, organization or institution with informa= tion

pertaining to the undersigned.

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A copy o= f this authorization shall constitute an original when it is signed by the

undersigned.

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This authorization shall be effective for six (6) months following the date of execution.

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Date:___________________________ = ; ________________________________

signature of appl= icant

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Witnesse= d by:______________________ ________________= ________________

printed name of witness &nbs= p; signature of witness

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