Employment Application Application for Employment Step 1 of 6 16% An Equal Opportunity Employer & E-Verify Participant Ottawa County Central Dispatch Authority (OCCDA) considers applications for all positions without regard to race, color, sex, age, religion, national origin, marital status, a person’s political affiliation, sexual orientation or gender identity, height, weight, disability, citizenship status, genetic information or any other legally protected status. Date of Application MM slash DD slash YYYY General InformationName* Last First Middle Address* Street Address Address Line 2 City ZIP Code Mobile/Cell Phone*Alternate PhoneEmail* Position(s) You Are Applying For What source referred you to OCCDA? Unemployment Office OCCDA Employee OCCDA Website Newspaper Ad Web/Online Ad Are you 18 years old or older?* Yes No Are you available for a full time position?* Yes No Are you available all shifts?* Yes No Date you are available* MM slash DD slash YYYY Rate of Pay Desired/Expected Are you authorized to work in the United States?* Yes No Have you ever applied for a position with OCCDA before? Yes No If Yes, what position and when (month & year): Have you ever been employed by OCCDA before? Yes No If Yes, what position and when (month & year): List any relatives currently working for or contracted by OCCDA:Have you ever been suspended or discharged from a former employer? Yes No If Yes, please explain:Do you have any employment records under a name other than the one listed above? Yes No If yes, please list additional names: Michigan law requires employers to make accommodations to applications who are persons with disabilities and such employees where the accommodation does not impose an undue hardship on the employer. Persons with disabilities who are employees and applicants may request an accommodation of their disability by notifying the Employer in writing of the need for accommodation within 182 days of the date the person knows or should know that an accommodation is needed. Failure to properly notify the Employer will preclude any claim that the Employer failed to accommodate the person with disabilities. Can you perform the essential job functions for the position(s) you are applying either with or without a reasonable accommodation? Yes No Do you have a valid Michigan Driver’s License? Yes No Driver’s License #: State of Issue: Expiration Date: Endorsements (CDL, etc.): **SPECIAL NOTE – All OCCDA positions require criminal background checks on prospective employees** Have you been convicted of a crime or do you currently have criminal charges pending against you?* Yes No If yes, please describe (include location and date):Please list all civil infractions – parking tickets, speeding tickets, etc. – in the last five years (include location and date):Please list any special skills, abilities, and interests you feel could be an asset: EducationHigh School/GED/Other Dates Attended (mm/yy - mm/yy) Areas of Specialization Did you graduate? Yes No Degree Earned College Dates Attended (mm/yy - mm/yy) Areas of Specialization Did you graduate? Yes No Degree Earned Graduate School Dates Attended (mm/yy - mm/yy) Areas of Specialization Did you graduate? Yes No Degree Earned List other formal education or licenses you feel are relevant to the position for which you are applying: Work ExperienceList all jobs you have held and periods of unemployment in the past ten (10) years. Put your present or most recent job first. If you need more room, please feel free to upload your resume at the bottom of this page. Name & Address of Employer Date of Employment (mm/yy - mm/yy) Title/Position Name of Supervisor Wage/Salary Full Time Part Time Duties of PositionReason(s) for LeavingName & Address of Employer Date of Employment (mm/yy - mm/yy) Title/Position Name of Supervisor Wage/Salary Full Time Part Time Duties of PositionReason(s) for LeavingName & Address of Employer Date of Employment (mm/yy - mm/yy) Title/Position Name of Supervisor Wage/Salary Full Time Part Time Duties of PositionReason(s) for LeavingResume/Cover Letter Drop files here or Select files Max. file size: 40 MB. Professional ReferencesPlease list FOUR professional referencesName First Last Email PhoneYears Known Relationship Name First Last Email PhoneYears Known Relationship Name First Last Email PhoneYears Known Relationship Name First Last Email PhoneYears Known Relationship Place of ResidencePlease list all addresses you have resided/lived during the last ten (10) years. Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rent Own Dates of Residence (mm/yy - mm/yy) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rent Own Dates of Residence (mm/yy - mm/yy) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rent Own Dates of Residence (mm/yy - mm/yy) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rent Own Dates of Residence (mm/yy - mm/yy) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rent Own Dates of Residence (mm/yy - mm/yy) Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Rent Own Dates of Residence (mm/yy - mm/yy) Additional InformationPlease list any additional information not already covered in this application. Disclaimer & Digital Consent I certify that my answers are true and complete. I authorize investigation of all statements, including references, contained in this application for employment as may be necessary in arriving at an employment decision. I also specifically waive any written notice requirements of Section 67 of 1978 PA 397 pertaining to disciplinary reports, letters of reprimand or other disciplinary actions. I also waive any claim against the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY and all current or former employers arising from such investigation or disclosure, including, but not limited to, slander and libel, that may result from furnishing any information to the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, in the absence of an express written contract or agreement to the contrary; any employment relationship with the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY is of an “atwill” nature, which means that the employee may resign at any time and the Employer may discharge employee at any time with or without cause. The undersigned applicant agrees, authorizes and consents to the procurement of a Consumer Report and/or an Investigate Consumer Report and understands that it may contain information about the applicant’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. I certify that the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY has provided a separate notice of my rights under the Fair Credit Reporting Act. In the event of employment, I understand that false or misleading information given in my application or interview(s) would be grounds for discharge. I understand, also, that I am required to abide by all rules and regulations of the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY. I further understand that if I am offered employment, a physical which may include drug testing (at the OTTAWA COUNTY CENTRAL DISPATCH AUTHROITY’s expense) may be required, proof of educational and licensing attainment must be submitted, and if any driving will be done for the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY purposes, I must be both eligible to drive and be qualified for insurance coverage. Employment by the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY is conditioned upon such results being satisfactory to the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY. Consent* I agree that any action or suit against the OTTAWA COUNTY CENTRAL DISPATCH AUTHORITY or its board elected or appointed officials, officers and/or employees arising out of my application for employment, subsequent employment, or termination of employment, including but not limited to claims arising under State or Federal civil rights statutes, must be brought within 180 days of the event giving rise to the claims or be forever barred. I waive any limitation periods to the contrary.Date of Consent* MM slash DD slash YYYY CAPTCHA By submitting this application and signing electronically, I agree my electronic signature is the legal equivalent of my manual signature on the application. I understand my electronic signature is as valid as if I signed the document in writing and no certification authority or other third party verification is necessary to validate my signature. NameThis field is for validation purposes and should be left unchanged.
