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PERSONAL INFORMATION

Last Name*
First Name*
Middle
Address1*
Address2
City*
State*
Zip*
Home Phone Number*
Mobile Phone Number
Email Address
Are you legally eligible for employment in the U.S.?*
1. Yes
1. No
Pittsfield Charter Township conforms to the Immigration Reform and Control Act of 1986 which requires you to furnish documentation showing your identity and legal authorization to work in the United States once you have been offered employment.
POLICE/FIRE APPLICANTS ONLY: Are you a U.S. citizen?
1. Yes
1. No
Are you 18 years or older?*
1. Yes
1. No
Date you are available to begin work:*
If you are related to anyone in our employ, state name and relationship to you.
Upload Your Resume
Must be a PDF
Upload a Cover Letter
Must be a PDF
Upload another document
Must be a PDF
Upload another document
Must be a PDF
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POSITION INFORMATION

EDUCATION

High School
Location
Degree(s) Earned or No. of Years Completed
College / University
Location
Degree(s) Earned or No. of Years Completed
Other
(Vocational, Trade, Graduate School, Professional Designation, etc.)
Location
Degree(s) Earned or No. of Years Completed
What languages (other than English) do you speak, read, or write?
Level of Fluency
Ability
1. Speak
1. Read
1. Write
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LICENSES, CERTIFICATIONS & SPECIAL TRAINING

Do you have any special training skills, qualifications, licenses, certifications, or other experiences that relate to the position(s) applied for?
Although a valid Michigan driver's license is required for all Pittsfield Charter Township jobs, exceptions are made for certain non-driving jobs if the applicant, who is otherwise qualified for a position for which they applied, is unable to obtain a license because of a physical or mental disability. A license check will be conducted.
Type of License
1. Operator's License
1. Chauffeur's License
1. Commercial Driver's License (CDL)
License Number
Expiration Date
Endorsements
Current Number of Points
A license check will be conducted for applicants for positions requiring a current driver's license.
U.S. Military Service:
Branch of Service
From
To
Rank or Rating
Type of Discharge
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EMPLOYMENT INFORMATION

REFERENCES

Please list three professional references, not related to you, whom you have known for over a year.
Full Name
Relationship
Occupation
Email Address
Phone Number
Years Known
Full Name
Relationship
Occupation
Email Address
Phone Number
Years Known
Full Name
Relationship
Occupation
Email Address
Phone Number
Years Known
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POLICE APPLICANTS ONLY

Are you certified or have you completed the Michigan Commission on Law Enforcement Standards (MCOLES) basic police training to be a certified law enforcement officer in the State of Michigan?
Written
1. Yes
1. No
Date Completed
Physical
1. Yes
1. No
Date Completed
Have you completed an MCOLES approved police academy?
1. Yes
1. No
Name of Academy
Date Completed
Provide copy of MCOLES Certification / Certifiability or out-of-state Law Enforcement License
Have you completed the MCOLES waiver of training program?
1. Yes
1. No
Date Completed
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PARKS & RECREATION APPLICANTS ONLY

Please indicate which of the following American Red Cross certifications you may hold
First Aid
1. Yes
2. No
Date Expires
Advanced First Aid
1. Yes
2. No
Date Expires
CPR
1. Yes
2. No
Date Expires
Water Safety
1. Yes
2. No
Date Expires
Other Certifications Not Listed
List all Youth Activities (sports, dance, fitness, arts-and-crafts, day camp, etc.) you feel qualified to supervise, instruct, direct, or referee:
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PRE-EMPLOYMENT MEDICAL EXAMS & DRUG SCREENING

Medical Examinations. In accordance with applicable legal requirements, Pittsfield Charter Township may require job applicants to undergo a medical examination after an offer of employment has been made and prior to the commencement of employment duties, and may condition the offer of employment on the results of such examination.
___________________________________________________________________________________________ I HEREBY CERTIFY THAT I AM NOT CURRENTLY ENGAGED IN THE ILLEGAL USE OF DRUGS. I understand that as a condition of employment, I may be required to take a pre-employment drug test for the illegal use of drugs which may include the collection of urine samples from my person. I agree that the results of this test may be submitted to Pittsfield Charter Township or its authorized representative, and I expressly release the collection agency and the testing laboratory from any and all liability for performing the requested test, and for communicating the results to the Township. I understand that if the results of any pre-employment drug test are positive, it will be cause for rejection of my application or, if I am hired, that my employment with the Township may be immediately terminated.
APPLICANT SIGNATURE
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SIGNATURE (Read carefully before signing)

• I certify that the answers and information given by me in this application are true, correct and complete without qualification. I understand that Pittsfield Charter Township has the right to refuse to hire or immediately discharge me, at any time, if it discovers that I have provided incomplete, untrue, or misleading answers or information in this application or on any other documents or forms submitted at any time during my employment.
• I hereby authorize Pittsfield Charter Township to verify the answers and information given by me in this application and to make any investigation on my background deemed necessary. I authorize former employers, law enforcement organizations, educational institutions, and any other third party contacted by the Township to release to the Township any information they have regarding me without providing written notice to me.
• I authorize Pittsfield Charter Township to use any information in its possession concerning me for any purpose it deems appropriate, including disclosure of information to any third party, future employer or prospective future employer without notification to me of such disclosure, and I release the Township from any liability in connection with such use or disclosure.
• If I am hired by Pittsfield Charter Township, I understand and agree that I will be bound by the rules, regulations, policies, procedures, and other terms and conditions of employment of the Township, as they are from time-to-time changed, with or without notice.
• If I am hired by Pittsfield Charter Township, I understand that I have the right to terminate my employment at any time and for any reason, with or without notice. I further understand that, except as set forth in any collective bargaining agreement, the Township can terminate the employment relationship at any time for any lawful reason, with or without cause, with or without notice. This employment relationship exists regardless of any other written statements or policies or any other Township document or any verbal statements to the contrary. No one except the Township Supervisor can enter into any kind of employment relationship or agreement which is contrary to the above. To be enforceable, any employment relationship or agreement which is contrary to the above must be in writing and personally signed by the Township Supervisor, and be attested by the Township Clerk.
• I agree not to commence any action or claim relating to my employment with Pittsfield Charter Township or this application for employment more than six (6) months after the date of the challenged action or this application, and to waive any statute of limitations to the contrary.
Your electronic signature below indicates your agreement with the following statements:
By typing my name in the following box and clicking submit button I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information.
APPLICANT SIGNATURE*

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PERSONAL INFORMATION

POSITION INFORMATION

EDUCATION

LICENSES, CERTIFICATIONS & SPECIAL TRAINING

EMPLOYMENT INFORMATION

REFERENCES

POLICE APPLICANTS ONLY

PARKS & RECREATION APPLICANTS ONLY

PRE-EMPLOYMENT MEDICAL EXAMS & DRUG SCREENING

SIGNATURE (Read carefully before signing)

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