INSTRUCTIONS To the Applicant: We appreciate your interest in the South East Regional Emergency Services Authority and assure you that we are interested in your qualifications. A clear understanding of your background and work history will aid us in the application process. Your application must be filled out completely with no blanks for proper processing. We recommend a completed application accompanied with a proper resume and cover letter attached.

We are an equal opportunity employer and shall consider qualified applicants for all positions without regard to race, color, sex, religion, national origin, age, height, weight, familial, marital or veteran status, or handicap. Incomplete applications may not be considered.

Orientation Date: - The November 9th date is now FULL - Please check the November 10th date 
11/9/2017 - FULL       11/10/2017

PERSONAL
Name:  
  (Last) (First) (Middle)
Address:  
City/State/Zip:  
Home Phone:  
Day Time Phone:  
  (Between 8 am-4 pm, M-F) 
Email Address:  
(SERESA will be communicating with you via email as to your status in the hiring process.)

Last 4 digits of Social Security Number:  

Are you 18 years of age or older?  Yes No
Are you authorized to work in the United States?  Yes No

Have you been previously employed by SERESA or any of the Jurisdictions that SERESA serves?  Yes No
If so, what agency and dates(s):  
What positions have you worked?  
Supervisor's Name:  

Have you filed an application with SERESA before?  Yes No
If yes, what are the dates(s): 

List any relatives or friends working for SERESA or any of the Jurisdictions that SERESA dispatches for here:


In order to check and verify your work record, have you ever been known by another name?  Yes No
If so, please provide name and explanation: 

EMPLOYMENT
Position(s) applied for: 

Kind of Work Sought:  Full-time Part-time Other: 
If part-time, please specify hours and days desired: 

Salary Desired:   Date Available to Work:  

How did you hear about this position? 

MILITARY SERVICE RECORD
Have you had any experience in the Armed Forces of the United States or in a State National Guard?  Yes No
If yes, what branch?   Rank at discharge:   Date of Discharge:  
Did you receive an Honorable Discharge?  
Are you in the Reserves?   Yes No If yes, date obligation ends:  
Special/Technical Training:  
EMPLOYMENT EXPERIEMCE (List current or most recent job first- past 8 years minimum).
1 Employer:
Address:
Phone Number:
Job Title:
Supervisor:
Work Performed/Duties:
Employment Dates:
From:  
To:  
Hourly Rate/Salary:
Beginning:  
Ending:  
Reason for leaving:
2 Employer:
Address:
Phone Number:
Job Title:
Supervisor:
Work Performed/Duties:
Employment Dates:
From:  
To:  
Hourly Rate/Salary:
Beginning:  
Ending:  
Reason for leaving:
3 Employer:
Address:
Phone Number:
Job Title:
Supervisor:
Work Performed/Duties:
Employment Dates:
From:  
To:  
Hourly Rate/Salary:
Beginning:  
Ending:  
Reason for leaving:
4 Employer:
Address:
Phone Number:
Job Title:
Supervisor:
Work Performed/Duties:
Employment Dates:
From:  
To:  
Hourly Rate/Salary:
Beginning:  
Ending:  
Reason for leaving:
5 Employer:
Address:
Phone Number:
Job Title:
Supervisor:
Work Performed/Duties:
Employment Dates:
From:  
To:  
Hourly Rate/Salary:
Beginning:  
Ending:  
Reason for leaving:
OTHER DISPATCH, LAW OR FIRE AGENCIES to which you have applied.
Name of Agency Location Year
Applied
Present Hiring/
Employment Status
EDUCATION
Type Name/Location (Address, City, State) Years
Completed
Diploma/
Degree
Course of Study
Elementary
Middle/Junior
High School
High School
College
Graduate
Vocational
School
Other
(Specify)
Other
(Specify)
Other
(Specify)
REFERENCES
Do not include relatives or former employers. Include at least two (2) peer references (must be within five years of your age)
Name Address Telephone
Number
Years
Known
1
2
3
4
ADDITIONAL INFORMATION
Have you been convicted of a crime?  Yes No
If so, where, when and nature of offense: 

Do you have any criminal charges pending against you?  Yes No
If so, where, when and nature of offense: 

Have you used any illegal substances within the last six months?  Yes No
If Yes, please list the type and circumstance. (Answering “Yes” to this question is not an automatic disqualifier for a job with this agency)

Do you have a valid driver's license?  Yes No
License Number:    State: 

List the social media sites you belong to: 

State any additional information that you feel may be helpful to us in considering your application:

AUTHORIZATION AND
UNDERSTANDING

RELEASE OF PRIOR PERSONNEL
RECORDS

BY SIGNING THIS APPLICATION, I AGREE THAT ALL OF THE INFORMATION NOW OR LATER GIVEN BY ME IN SUPPORT OF MY application for employment is true and complete. I understand that you may verify any of the information concerning my employment, education, credit or medical history with the appropriate individuals, organizations, or governmental agencies. I give these individuals, organizations, or governmental agencies my permission to release any information that you need, including my previous disciplinary record, without requiring them to contact me or give me written notice before revealing the information to you. I understand that no verification of my credit history or request for a "consumer report" under the Fair Credit Reporting Act may be undertaken by you without my express written authorization in a separate document. By signing this application, and in the case of a consumer report under the Fair Credit Reporting Act, should I sign the separate Authorization for credit reports on me, I release you and them from any liability whatsoever arising out of any information request or disclosure. I agree that any false information in support of my application may subject me to discharge at any time during my employment.

AT-WILL EMPLOYMENT
STATUS

I AGREE THAT FOR Supervision and Probationary Employee Status, EITHER PARTY MAY TERMINATE THE EMPLOYMENT RELATIONSHIP, WITH OR WITHOUT CAUSE, AT ANY TIME, FOR ANY REASON, AND I FURTHER AGREE THAT THIS ARRANGEMENT MAY ONLY BE CHANGED BY THE Director OF South East Regional Emergency Services Authority (SERESA), IN WRITING, DIRECTED TO ME PERSONALLY, AND SIGNED BY THE Director. I agree that I shall be bound by the other rules, policies, regulations, and terms and conditions of employment of SERESA as they are from time to time changed and that no additional obligations can be imposed by me on SERESA except those which have been acknowledged, in writing, by the Director or his/her designated representative. I further agree that my employment is conditional upon satisfactory completion of documentation as required by the Immigration Reform and Control Act of 1986 and until such time as the results of my pre-employment physical (if such physical is required) are known.

Handicap Accommodation Request

I UNDERSTAND THAT MICHIGAN LAW REQUIRES EMPLOYERS TO MAKE ACCOMMODATIONS TO HANDICAPPED APPLICANTS AND EMPLOYEES WHERE THE ACCOMMODATION DOES NOT IMPOSE AN UNDUE HARDSHIP ON THE EMPLOYER. I further understand handicapped employees and applicants may request an accommodation of their handicap by notifying SERESA in writing of the need for accommodation within 182 days of the date the handicapper knows or should know that an accommodation is needed. Failure to properly notify SERESA will preclude any claim that the employer failed to accommodate the handicapper under Michigan law.

I acknowledge that I have read the above statements and agree to its terms and conditions

AUTHORIZATION TO RELEASE INFORMATION

We appreciate your interest in employment opportunities with SERESA. As part of our normal procedure during the pre-employment process, we may perform a routine inquiry into your background based on the information you have provided us. In order for such information to be released, we need your concurrence. Therefore, please read the following statement carefully and indicate your agreement by signing below.

TO WHOM IT MAY CONCERN:

I hereby authorize the South East Regional Emergency Services Authority (the "Employer"), or other authorized representative of the Employer, within one (1) year from the date hereof, to obtain any information in your files pertaining to my employment, military record, credit record, law enforcement record, medical or educational records, including, but not limited to, academic, achievement, attendance, criminal, personal history and disciplinary records. I hereby direct you to release such information upon request of the Employer or its authorized representative. I hereby release the Employer and any authorized representative, as custodian of such records, and any school, college, university, or other educational institution; hospital, or other repository of medical records; credit bureau; law enforcement agency; lending institution; consumer reporting agency; or other business establishment, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages whatsoever, which may at any time result to me, my heirs, family or associates because of the Employer's request for and/or review of records described in this Authorization to Release Information. Should there be any questions as to the validity of this Release, you may contact me as indicated below.

If you would like to attach a resume, you may send a PDF or Word Document file below:

By entering your name in the box below, you are providing your signature to this document and all agreements included within and affirming your identity.

Signature:     Date:  10/22/2017