THE COUNTY OF OTTAWA EMPLOYMENT APPLICATION Human Resources Department GENERAL INFORMATION

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1 GENERAL INFORMATION Complete all sections of this application. An incomplete application may result in your application not receiving further consideration. This application for employment will only be considered for the open position(s) listed, and will expire after the recruitment period is completed or the position is filled. Position Applying for: Position Applying for: Position Applying for: Name in Full: THE COUNTY OF OTTAWA EMPLOYMENT APPLICATION Human Resources Department Fillmore Street, West Olive, MI Telephone (616) Web Site Please Print Date: Address: Telephone: Address: Street City State Zip Alternate Telephone: Are you a current Ottawa County Employee? Yes No Do you have relatives working for Ottawa County? Yes No What Department? Have you ever been employed by Ottawa County? Yes No if yes where? Have you ever been discharged/fired from employment? Yes No if yes, please explain: Have you ever resigned/quit after being informed that your employer intended to discharge/fire you? Yes No if yes please explain: Do you have a valid Michigan Drivers License: Yes No Have you ever been convicted of a crime? If YES, give offense, date, county, state and sentence for each conviction: Do you have any felony charges pending? If Yes, please explain: An Equal Opportunity Employer

2 MILITARY EXPERIENCE Are you a veteran? From: To Highest Rank Branch Are you a current member of Armed Military Reserves? Yes No EDUCATIONAL INFORMATION Proof of Education and/or Professional Registration(s), License(s), and Certification(s) will be required prior to hire/promotion. Education Name of H igh School, College, Trade, or Technical Schools City and State Did You Graduate? Course of Study/Degree Received/Certifications GPA High School: Yes No GED College, Trade, or Tech: Yes No Credit Hours Completed: College, Trade, or Tech: Yes No Credit Hours Completed: College, Trade, or Tech: Yes No Credit Hours Completed: Special Training: (Please state fully any training you have had) Language Proficiency (Other than English): Please Circle level in which you feel is your highest level in that language 05/10

3 PRIOR WORK HISTORY (Please do not use see resume an incomplete application may result in your application not receiving further consideration) Most Recent Dates of Employer Employment: From to Address Position Held: _ Street City State Country Zip Phone Reason for Leaving: Supervisor: May we contact this person? Yes No Description of Duties: Salary or Earnings Starting: Ending: Hr. Wk. Yr. Dates of Employer Employment: From to Address Position Held: _ Street City State Country Zip Phone Reason for Leaving: Supervisor: May we contact this person? Yes No Description of Duties: Starting: Ending: Salary or Earnings Hr. Wk. Yr. Dates of Employer Employment: From to Address Position Held: _ Street City State Country Zip Phone Reason for Leaving: Supervisor: May we contact this person? Yes No Description of Duties: Salary or Earnings Starting: Ending: Hr. Wk. Yr. PROFESSIONAL REFERENCES Please list three current/former employers, supervisors, etc. who are familiar with your past work and skills. Name Title Company Phone Number Name Title Company Phone Number Name Title Company Phone Number 06/09/08

4 Ottawa County Human Resources Supplemental Application for Employment Road Patrol Deputy 1. Last Name First Name Middle Name 2. Date of Birth 3. Other Names, Alias(es), Nickname(s) 4. To meet the minimum qualifications set out by the Michigan Commission on Law Enforcement Standards (MCOLES), you must answer YES to the following four (4) statements: Yes No I am at least 18 years old Yes No I am a United States citizen Yes No I have a high school diploma or GED Yes No I possess a valid Michigan operator s or chauffeur s license 5. To meet the minimum qualifications set out by the Michigan Commission on Law Enforcement Standards (MCOLES), you must answer NO to the following two (2) questions: Yes No Do you have any previous felony convictions? Yes No Have you ever been convicted of a misdemeanor crime involving domestic violence? (Such a conviction would make an individual ineligible to possess a firearm) 6. In order to be considered for this position, you must possess or will become eligible to possess a Michigan Commission on Law Enforcement Standards (MCOLES) License. Please identify the manner in which you are meeting this requirement. Option 1: I hold a current MCOLES License This license was activated by (police agency) on (date license was activated). MCOLES # Option 2: I am currently MCOLES licensable I graduated from (police academy) on (date). Option 3: I am currently enrolled in a certification academy and am scheduled to graduate and become licensable by (date of graduation from academy ) Option 4: I am currently a law enforcement officer in the U.S. Military or in another state. I understand that I must contact the Michigan Commission on Law Enforcement Standards for information on a waiver of training. 7. Previous Residential Addresses Month & Year From To Address City State

5 8. Knowledge of foreign languages and level of proficiency (please check all that apply) Understand Speak Read Write Spanish Vietnamese Other ( ) Other ( ) Other ( ) 9. Please list any additional training, experience or special ability(ies) that would be pertinent to the position of Road Patrol Deputy (i.e. Emergency Medical Training, First Aid, CPR, Military Training, etc.) Please explain 10. Are you currently proficient in the use of firearms? Yes No 11. Are you currently proficient in any form of the marital arts? Yes No 12. Are you willing to train and become proficient in these areas? Yes No 13. Driving History Driver s License (Please provide the following information concerning any driver s license you have held or now hold) Have you ever been involved in a motor vehicle collision while operating the vehicle? Yes Please give details of the incident. No List all traffic citations ever received (except parking) 14. Controlled Substances Do you now or have you ever, used or sold any form of controlled substances? Yes No If yes, please complete the following Name of Drug Date of Last Use

6 15. Organization Membership List organizations to which you currently belong or have belonged to in the past. Include civic, social, fraternal, etc. (Do not include any organizations in which membership would indicate your race, color, religion, national origin or ancestry). Indicate any offices held. Are you now or have you ever been a member of any group or organization which advocates the violent overthrow of the local, state or Federal government? Yes No If yes, describe the organization and the circumstances 16. In what hobbies, sports or other extracurricular activities have you participated or do you participate in on a regular basis? 17. List any awards, significant recognition or accomplishments that you have received 18. Personal References List five (5) persons (not related to you and not former employers) who have known you well for five (5) years or more Name Street Address City/State Phone

7 PLEASE READ THE FOLLOWING AND SIGN BELOW: Pursuant to 42 USC et. seq. and MCL et. seq., an individual having a protected disability under either Act needing accommodations for employment is required to notify the employer in writing, within 182 days after the need is known. In consideration of my employment, I agree to conform to the rules and regulations of Ottawa County and that my employment can be terminated with or without cause and with or without notice at any time, at the option of either the County or myself. I understand that my employment with Ottawa County is not to be construed as any form of guarantee of continued employment, working conditions, rights or benefits. I realize that the County s policies, procedures and rules can be changed at any time and that any changes will be effective immediately upon notice to employee. I understand that no manager, department head or representative of the County of Ottawa other than the County Administrator has any authority to enter into any agreement for employment for any specified period of time, or make any agreement contrary to the foregoing. Any such agreement is effective only if in writing. I affirm that all information in this application is true and complete. Any misrepresentation, false statement, or omission of facts called for in this application, in any subsequent interview, or any other part of the employment process shall be grounds for refusal of employment or if hired, dismissal from employment. I authorize my employer and former employers, schools, or persons named to give any information regarding my employment, together with any information they may have regarding me, whether or not it is in their records. I hereby release said employers, schools, or persons from all liability for any damage for issuing this information. I authorize Ottawa County to conduct a criminal background check with the F.B.I., State Police, County Sheriff department and/or a consumer reporting agency for the purpose of determining my suitability for employment with Ottawa County. I have listed all crimes for which I have been convicted, including the date of such conviction, as well as any pending felony charges. I acknowledge that any omission or falsification of this form shall be grounds for discharge if I am employed, or grounds for Ottawa County to refuse to further consider my application for employment. I authorize the County of Ottawa to copy this document and agree that such copies with my signature shall have the same legal force and effect as the original document with my signature. Signature: _Date: Print Previous Name(s), if different Driver s License Number, State & Country or I.D. Number and State Social Security Number 06/09/08

8 How did you learn about this position? (Please check all the apply) From County Employee County Job Announcement Ottawa County Website Training Agency (Name): Community Agency (Name): Newspaper: If so which newspaper? Other Source (please be specific): 06/09/08

9 Ottawa County requests that you supply, on a voluntary basis, the information sought below. Completion of this form is strictly VOLUNTARY. The information is for record keeping purposes only and will in no way effect any employment decision. This confidential questionnaire will be kept separately from your Application for Employment. VOLUNTARY INFORMATION Your voluntary completion of this form will assist the County in compiling required information for Equal Employment Opportunity (EEO). Please complete and return with your employment application. This information will not be used to evaluate your application. Position applying for: Sex: Male Female Ethnicity: American Indian or Alaska Native Asian Black or African-American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Handicapped: Yes No Veteran: Yes No U.S. Citizen: Yes No Date of Birth: 06/09/08