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APPLICATION FOR EMPLOYMENT

 

The City of Madison Heights is an equal opportunity employer and shall consider all qualified applicants for all positions without regard to race, color, sex, religion, national origin, age, height, weight, marital status, veteran status, handicap, or any other protected category.

YOU MUST ANSWER ALL QUESTIONS COMPLETELY AND TRUTHFULLY.  FAILURE
TO DO SO WILL RESULT IN REJECTION OF YOUR APPLICATION (YOU WILL
NOT BE CONSIDERED FOR EMPLOYMENT), OR, IF NOT DISCOVERED UNTIL A LATER DATE, MAY RESULT IN DISCIPLINE OR DISCHARGE FROM EMPLOYMENT. 

* INDICATES A REQUIRED FIELD.
*Position(s) Applied for:  
*Last Name:     *First Name:     *Middle Name: 
*Street Address: 
*City:       *State:      *Zip Code: 
*Telephone:      *Social Security No: 
*Email
*Driver's License No. 


*Are you a relative by birth or marriage to any City of Madison Heights elected official or full-time management employee?    

If Yes: 
Name:   Relationship: 
*Are you under 18 years of age?
*Are you currently working?
*Are you currently on lay-off? 
If yes, are you subject to recall? 
*Will you submit to a drug screening test? 
*Have you ever been employed by the City of Madison Heights?
If Yes: 
Position:      Department:    Dates:   
*Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status?
(Proof of citizenship or immigration status may be requested upon employment)
*Have you ever been fired?
If Yes, give date, where you worked and explanation: 
*Have you ever been convicted of a felony?
If Yes, completely describe including location and date: 
NOTE: A conviction record will not necessarily be a bar to employment. Factors such as age, time of offense, seriousness and nature of violation, and rehabilitation will be considered.
*Are you capable of performing with or without reasonable accommodation (special assistance, equipment or other help), the activities involved in the job or occupation for which you have applied? 
*Describe how you would perform the job functions involved in the job or occupation for which you have applied: 


EDUCATION
*High School:      *City:     *State: 
*Did you graduate?
*Degree/ Certification:      *Major/ Minor: 


Vocational/Tech School:     City:    State: 
Did you graduate?
Degree/ Certification:     Major/ Minor: 


College:     City:    State: 
Did you graduate?
Degree/ Certification:     Major/ Minor: 


Graduate School:     City:    State: 
Did you graduate?
Degree/ Certification:     Major/ Minor: 


*Describe any specialized training, apprenticeships, internships, skills, licenses, certificates, and extra-curricular activities that pertain to the position(s) for which you are applying: 
*List professional, trade, business group memberships and offices held and volunteer work excluding groups the name and character of which indicate race, color, sex, religion, national origin, age, height, weight, marital status, veteran status, handicap, or any other protected class: 

REFERENCES: 
(Do not include relatives or former employers)

*Name:     *Address:     *Phone: 

*Name:     *Address:     *Phone: 

*Name:     *Address:     *Phone: 

MILITARY SERVICE RECORD
*Have you had any experience in the Armed Forces of the United States of America or in a State National Guard?  
If Yes, what branch?      Rank at discharge?   
Date of discharge?     Were you honorably discharged?   
NOTE: A dishonorable discharge from the military will not necessarily be a bar to employment.

EMPLOYMENT HISTORY

List each job held. Start with your present or last job first.

*Employer Name:  Dates: 
*Address & Telephone: *From:    *To:
*Job Title:  Hourly Rate / Salary: 
*Supervisor:  *Start:    *Finish:
*Reason(s) for leaving: 
*Work Performed: 


Employer Name:  Dates: 
Address & Telephone: From:    To:
Job Title:  Hourly Rate / Salary: 
Supervisor:  Start:    Finish:
Reason(s) for leaving: 
Work Performed: 


Employer Name:  Dates: 
Address & Telephone: From:    To:
Job Title:  Hourly Rate / Salary: 
Supervisor:  Start:    Finish:
Reason(s) for leaving: 
Work Performed: 


Employer Name:  Dates: 
Address & Telephone: From:    To:
Job Title:  Hourly Rate / Salary: 
Supervisor:  Start:    Finish:
Reason(s) for leaving: 
Work Performed: 


Employer Name:  Dates: 
Address & Telephone: From:    To:
Job Title:  Hourly Rate / Salary: 
Supervisor:  Start:    Finish:
Reason(s) for leaving: 
Work Performed: 


Employer Name:  Dates: 
Address & Telephone: From:    To:
Job Title:  Hourly Rate / Salary: 
Supervisor:  Start:    Finish:
Reason(s) for leaving: 
Work Performed: 


AGREEMENT AND UNDERSTANDING
1. I certify that the information in this application is true, complete and correct to the best of my knowledge and understand that falsification, misleading, misrepresentation or omission of any information submitted in connection with my application or interview, whether in this document or not, may result in rejection of my application or, if hired, in dismissal.

*


2. I waive written notice from my current employer and from any of my former employers regarding the disclosure of disciplinary reports, letters of reprimand, or other notices of disciplinary action contained in my personnel records (even if more than four years old). This waiver is made pursuant to the Bullard-Plawecki Employee Right-to Know Act.

*


3. I authorize the references and current and former employers listed in this application to give you any and all information concerning my current and previous employment and any pertinent information they may have (even if more than four years old) and release all parties from any liability for any damages that may result from furnishing same to you.

*


4. I authorize the City of Madison Heights to release any information (even if more than four years old) relating in any way to my employment including disciplinary reports, letters of reprimand or other notices of disciplinary action when such information is requested by any prospective or subsequent employers without any obligation (by them or you) to give me any notice of such disclosure.

*


5. I understand that any employment offer is conditional upon the results of the drug screening test, post offer preemployment medical examination, and criminal history check.

*


6. I authorize the City of Madison Heights to procure a consumer report as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for the City of Madison Heights to procure consumer reports at any time during my employment period.

*


7. I have read the job description as posted on the City’s website. If employed, I understand that if I am or become handicapped in need of accommodations for employment, I must notify the City of Madison Heights Personnel Department in writing within 182 days after the need is known or reasonably should have been known to me. The requirement is applicable under the Michigan Handicappers Act and this does not preclude any rights an applicant may have pursuant to the Americans with Disabilities Act of 1990, as amended. Failure to properly notify the City will preclude any claim that the employer failed to accommodate.

*


8. I authorize the City of Madison Heights to investigate my criminal history as determined necessary. I hereby release and discharge the City of Madison Heights, the Oakland County Sheriff’s Department, and/or the Michigan State Police and their agents from liability for any damage of whatever kind or nature, except for willful or intentional acts, that may result from release of this information to the City of Madison Heights.

*



FOR NON-UNION


9(A). In consideration of my employment, I agree to conform to the rules and regulations of the City of Madison Heights, as they may be amended or changed from time to time, and I agree that my employment and compensation can be terminated with or without cause and with or without notice at any time at the option of either the City or myself. I understand that no officer or representative of the City has the authority to enter into an agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing, except the City Manager of the City or his designee and any such agreement must be made in writing, directed to me personally. I further acknowledge that no one has made any representations or statements to the contrary to the City's employment at will policy or about the City's economic outlook or stability to me, either oral/or in writing, and I acknowledge and understand that no one has the authority to make such representations or statements to the contrary in the future.

FOR THE UNION


9(B). In consideration of my employment, I agree to the rules and regulations of the City of Madison Heights. I further acknowledge I will be on probationary status for a period determined by the Union contract and/or City personnel rules and regulations. As a probationary employee, I understand my employment and compensation can be terminated at any time with or without cause and with or without notice at the option of either the City or myself. I understand that no officer or representative of the City has the authority to enter into an agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing, except the City Manager of the City and his designee and any such agreement must be made in a signed writing directed to me personally. I further understand that after my probationary period ends, I will be subject to the terms and conditions of the collective bargaining agreement between the City of Madison Heights and pertinent union. I acknowledge that no one has made any representations or statements contrary to the City's probationary at-will policy to me or about the City's economic outlook or stability either orally or in writing, and I acknowledge that no one has the authority to make such representations or statements to the contrary in the future.
10. I agree that any lawsuit against the City arising out of my employment or termination of employment, including but not limited to, claims arising under the State or Federal Civil Rights statutes, must be filed within six months of the event giving rise to the claims or be forever barred. I waive any limitations period to the contrary.

*


COMPLETE ALL QUESTIONS IN THIS SECTION. THE INFORMATION REQUESTED HEREIN IS NECESSARY TO COMPLY WITH GOVERNMENTAL RECORD KEEPING AND REPORTING REQUIREMENTS.
*CHECK THE BOX THAT APPLIES TO YOU: 

*REFERRAL SOURCE: