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CHARTER TOWNSHIP OF CANTON
HUMAN RESOURCES DIVISION
1150 CANTON CENTER ROAD S
CANTON, MI 48188
(734) 394 5260 - YOly2yYkY23
MCOLES
PLEASE COMPLETE THIS APPLICATION & RETURN TO HUMAN RESOURCES BY MAIL OR IN PERSON
Application for Employment
(Applicant must type or print legibly in ink)
APPLICATIONS ACCEPTED DURING CURRENT POSTINGS NEED TO BE RECEIVED BY POSTED DEADLINE
EXACT TITLE OF POSITION APPLIED FOR: ______________________________________________________________
(Please complete a separate application for each position you are applying for)
DATE OF APPLICATION _________________________
NAME _________________________________________________________________________________________
LAST FIRST MIDDLE
ADDRESS_______________________________________________________________________________________
NUMBER STREET CITY STATE ZIP CODE
PHONE NUMBER ( ) _____________________ EMAIL ADDRESS____________________________________
If necessary, best time to call you at home is .. _________________________
May we contact you at work? Yes No
If yes, work number and best time to call ( ) _______________________ Time _____________________
Are you at least 18 years of age? .. Yes No
If you are under 18, can you furnish a work permit? . Yes No
Have you filed an application here before? Yes No If yes, give date/position ________________________
Have you ever been employed here before? Yes No If yes, give dates FROM __________ TO _________
Are you legally eligible for employment in this country? Yes No
(Proof of U.S. citizenship or immigration status will be required upon employment: police and fire applicants must be U.S. Citizens.)
Date available for work . _______________________
Are there any days or times you would not be available to work? __________________________________________
Are you currently on a lay-off and subject to recall? .. Yes No
Veteran of the U.S. Military Service Yes No If yes, Branch ________________________________
Dates of Service _________________________________________________________________________________
Have you ever been convicted of any offense(s) while in the Military, National Guard or Military Reserves? Yes No
Have you ever been convicted of a felony? .. Yes No
If yes, please explain _____________________________________________________________________________
Drivers License Number ________________________________ State ____________________________________
Commercial Drivers License: Yes No If yes, Group ____ Endorsement _____ Expiration Date __________

How did you become aware of this employment position:
(PLEASE CHECK ONLY ONE)
Newspaper Advertisement ( Detroit News/Free Press Observer & Eccentric Michigan Chronicle)
Canton Townships Web Site
Other Web Site
Other ______________________________
The Charter Township of Canton does not discriminate against any individual or group because of race, sex, national origin,
color, marital status, handicap, J`uJJ J height, or weight in employment or the provision of services.
Canton takes great pride in the diversity of our community and promotes diversity in the workforce.
APPLICATION MUST BE COMPLETED IN ITS ENTIRETY BY APPLICANT

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Employment History

List your last three (3) employers, assignments or volunteer activities, starting with the most recent including military experience. Explain any gaps in employment in
comments section below. (If this doesnt cover the last 3 years, please list on separate sheet).
Name of Employer _______________________________________
Employer Contact Number ( ) ________________________
Employment Dates Summarize the nature of the work performed and
job responsibilities.
Start Date End Date
ADDRESS
JOB TITLE Hourly Rate/Salary

Starting
$ per

Hourly Rate/Salary

IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE?
Yes No Later

Name of Employer _______________________________________
Employer Contact Number ( ) ________________________
Employment Dates Summarize the nature of the work performed and
job responsibilities.
Start Date End Date
ADDRESS
JOB TITLE Hourly Rate/Salary
Hourly Rate/Salary

IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE?
Yes No Later

Name of Employer _______________________________________
Employer Contact Number ( ) ________________________
Employment Dates
Summarize the nature of the work performed and
job responsibilities. Start Date End Date
ADDRESS
JOB TITLE Hourly Rate/Salary
Hourly Rate/Salary


Final
$ per
IMMEDIATE SUPERVISOR AND TITLE
REASON FOR LEAVING
MAY WE CONTACT FOR REFERENCE?
Yes No Later


COMMENTS (including explanation of any gaps in employment)
______________________________________________________________________________________________________________________________
SKILLS AND QUALIFICATIONS Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for this position such
as licenses, certifications, etc. (Exclude information which would reveal sex, race, religion, national origin, age, handicap or other protected status.)
______________________________________________________________________________________________________________________________
APPLICATION MUST BE COMPLETED IN ITS ENTIRETY BY APPLICANT. DO NOT INCLUDE ANY EXTRANEOUS INFORMATION (BIRTH CERTIFICATE, LICENSE, ETC.).

Starting
$ per


Starting
$ per


Final
$ per

Final
$ per
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Educational Background

A. List last three (3) schools attended, starting with the last one. B. List number of years completed. C. Indicate degree or diploma earned,
if any. D. Grade Point Average or class rank. E. Major and minor field of study (if applicable)
A. SCHOOL
B. NO. YEARS
COMPLETED
C. DEGREE
DIPLOMA
D. GPA
CLASS RANK
E. MAJOR F. MINOR




List any foreign language(s) and check the box that best describes your skill level
LANGUAGE READ AND WRITE READ AND SPEAK
READ ONLY SPEAK ONLY



References
List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not
applicable, list three school or personal references that are not related to you.
NAME TELEPHONE YEARS KNOWN


List professional, trade, business or civic associations and any offices held. (Exclude memberships which would reveal sex, race, religion,
national origin, age, handicap, or other protected status.)
ORGANIZATION OFFICES HELD


List special accomplishments, publications, awards. (Exclude information which would reveal sex, race, religion, national origin, age,
handicap, or other protected status.)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
FOR POLICE AND FIREFIGHTER POSITIONS. Please check all that apply.
POLICE OFFICER REQUIREMENTS
Additional Information: _______________________________________________________________________________________

I am a certified Police Officer in the State of Michigan
I am currently enrolled in & attending a Police Academy
I completed the Police Academy on ________________
I have completed MCOLES Reading & Writing Exam
Date Completed: ______________________
I have completed MCOLES Physical Agility Test
Date Completed _______________ Expires _______________
FIREFIGHTER REQUIREMENTS:
I am certified through the State of Michigan as a Firefighter II
I possess a current, valid paramedic license
I am certified in Advanced Cardiac Life Support (ACLS)
I have completed the CWW Written Exam
Date Completed ________________ Expires _____________
I have completed the CWW Physical Agility Testing
Date Completed ________________ Expires ______________

APPLICATION MUST BE COMPLETED IN ITS ENTIRETY BY APPLICANT
DO NOT INCLUDE ANY EXTRANEOUS INFORMATION (BIRTH CERTIFICATE, LICENSE, ETC.)


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General Information

Has your employment ever been terminated involuntarily, including lay-offs, reduction in workforce?..................................... Yes No
If Yes, please explain: _____________________________________________________________________________________________
__________________________________________________________________________________________________________________
Have you ever supervised others? . Yes No
If Yes, please explain (Level, number of years, where): ____________________________________________________________________
__________________________________________________________________________________________________________________
Have you read the position description? .. Yes No
Can you perform the essential functions of the position applied for, with or without reasonable accommodation?................ Yes No
If no, please explain: ______________________________________________________________________________________________
_________________________________________________________________________________________________________________
Will you work overtime if required? .. Yes No
Do you have any relatives working for the Charter Township of Canton? .. Yes No
If Yes, please explain (who, including relationship): __________________________________________________________



















APPLICATION MUST BE COMPLETED IN ITS ENTIRETY BY APPLICANT
DO NOT INCLUDE ANY EXTRANEOUS INFORMATION (BIRTH CERTIFICATE, LICENSE, ETC.)
An applicant needing accommodations of a disability must provide written notification to the Charter Township of Canton
Human Resources Division within 182 days after the need is known or should have been known. Failure to do so may waive
certain rights under Michigan law.

I waive my right to written notice from present or former employers whenever they disclose to you a letter of reprimand,
disciplinary report or disciplinary action regarding me. Yes No
I agree and understand that any employment offer is conditional upon the results of the post-offer medical examination.
I hereby certify that all answers to the questions contained herein are true and accurate. I understand that the submission of
any false information in connection with any application for employment, whether on this document or not, may be cause
for immediate discharge at any time thereafter should I be employed by the Charter Township of Canton.
I give the Township the right to investigate all references and to secure additional information about me, if job related. I
hereby release from liability the Township and its representatives for seeking such information and all other persons,
corporations or organizations furnishing such information.
This application is current for ninety (90) days. At the conclusion of this time, if I have not heard from the Township and still
wish to be considered for employment, I will inquire as to whether or not new applications are being accepted.
_________________________________________________ _______________________
Signature of Applicant Date

LIMITATION ON TIME TO FILE SUIT
I agree that any lawsuit against the Township arising out of my employment or termination of employment, including but not
limited to claims arising under State or Federal civil rights statutes, must be brought within one year of the event given rise to
the claims or be forever barred, I waive any limitation period to the contrary.

_________________________________________________ _______________________
Signature of Applicant Date
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CHARTER TOWNSHIP OF CANTON AVAILABILITY RECORD
Name: __________________________________________ Position Applied For: ____________________________________

Address: ___________________________________________________________________________________________________

City, State, Zip Code: _______________________________________________________________________________________

Phone # : ________________________________________ Email Address : _________________________________________
I am available and seeking the following:
FULL TIME YEAR ROUND EMPLOYMENT - Please Note: By checking that you are available and seeking full-time year
round employment, you will exclude yourself from consideration for all seasonal and part-time positions for which you
are applying.
SEASONAL EMPLOYMENT A seasonal position may be scheduled to work up to 40 hours per week for a limited duration
of time (up to 6 months) on an at-will basis.
PART-TIME EMPLOYMENT Part-time positions are scheduled to work a limited number of hours (less than
29 hours per week) throughout the year on an at-will basis.



Reason for seeking this type of employment (i.e. student, retired, etc.): __________________________________
Do you have any limitations on your availability?
NO I am available to work days, nights, weekends and holidays as needed.
YES If yes, please complete the availability table below. Availability will be considered in the selection process. Please
check the appropriate box for each day of the week. If you have limited availability on certain days please list the hours
that you are available
Please
Check:
to work.
Available
(No Limitations)
Limited Availability
(Please list hours that you are available)
Not
Available
Sunday ______ a.m. /p.m. TO ______ a.m./p.m.
Monday ______ a.m. /p.m. TO ______ a.m./p.m.
Tuesday ______ a.m. /p.m. TO ______ a.m./p.m.
Wednesday ______ a.m. /p.m. TO ______ a.m./p.m.
Thursday ______ a.m. /p.m. TO ______ a.m./p.m.
Friday ______ a.m. /p.m. TO ______ a.m./p.m.
Saturday ______ a.m. /p.m. TO ______ a.m./p.m.
Do you limit your annual earnings due to social security or other reasons?
YES, AMOUNT $__________
NO
IF YOUR AVAILABILTY CHANGES, IT IS YOUR RESPONSIBILITY TO NOTIFY THE HUMAN RESOURCES DEPARTMENT AND FILL OUT ANOTHER
AVAILABILITY SHEET.

SIGNATURE: ______________________________________________ DATE: ____________________________
When selecting that you are available and seeking part-time or seasonal employment you acknowledge and understand that the
position is not and will not become a full-time year round budgeted position.
Part-time and seasonal positions are budgeted for limited hours from a limited resource of funds. Only those applicants that are
truly interested in part-time and seasonal employment should apply for part-time or seasonal positions as unemployment or
underemployment claims will reduce the funds available to fill existing part-time and seasonal positions.

6/12/2012 Page 6 of 6


CHARTER TOWNSHIP OF CANTON
HUMAN RESOURCES DIVISION
1150 CANTON CENTER ROAD, CANTON, MI 48188
(734) 394-5260

EQUAL EMPLOYMENT OPPORTUNITY DATA
In accordance with FEDERAL EQUAL EMPLOYMENT OPPORTUNITY GUIDELINES, the Charter Township of Canton is
required to maintain statistical data pertaining to the sex and race of job applicants. The information obtained
from this form is used for statistical purposes only and does not become part of your application for employment.
Please assist us in obtaining this required data by checking the appropriate boxes below. This is strictly voluntary;
if you choose not to participate, just check Not Participating".
Thank you for your cooperation.

Date: ____________________________
Position Applying For: ___________________________________________________
(Please include even if not participating in this survey.)


SEX ETHNIC GROUP RACE
Female African -American Black
Male Native American Native American
Arab American Asian
Pacific Islander/Oriental Hispanic
Hispanic Caucasian
European

No, thank you, Im not participating in this survey.