GogebicCounty

Board of County Road Commissioners

ART LYONS 200 NORTH MOORE STREET ROY MINKIN

Chairman Courthouse Annex Vice-Chairman

Ironwood Bessemer, Michigan 49911 Marenisco

DON BENNETTS (906) 667-0233 ROB DRIER

Commissioner (906) 667-0234 Commissioner

Bessemer FAX: (906) 663-4807 Wakefield

MARTI WEGNER E-mail: DARREN PIONK

Commissioner Engineer/Manager

Watersmeet Bessemer

I certify that the information contained in my employment application is true and accurate. I understand that falsification of this information will result in my dismissal from employment.

I understand that Gogebic County Road Commission may obtain a credit report about me. I authorize Gogebic County Road Commission may obtain such a report and to make an investigation of my employment history and my personal history through any investigative agencies or bureaus of its choice, and to contact my current and former employers. I authorize these references to give Gogebic County Road Commission any and all information concerning my previous employment and other pertinent information they may have, personal, or otherwise. I also authorize Gogebic County Road Commission to obtain a copy of my motor vehicle report. I hereby release all parties from any liability that may result from any investigation conducted and/or the release or furnishings of information to Gogebic County Road Commission.

I understand that upon an offer of employment, I may be required to pass a physical examination prior to employment, which may include a drug-screening test. I understand the Gogebic County Road Commission reserves the right to require a drug-screening test at any time during my employment.

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APPLICANT SIGNATUREDATE

FOR CDL OPERATORS ONLY:

I further understand that, if I am hired, I will be required as a condition of employment, to have and maintain a valid Michigan’s driver’s license at all times during my employment. I certify that I presently have a valid Michigan’s driver’s license. I further understand that if I am hired, I will be required to notify my employer of any and all motor vehicle violations placed on my license within five (5) working days of such a conviction and immediately if there is the imposition of any limitation on my license. I will be given a form to report any and all such violations and/or limitations to my employer.

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APPLICATANT SIGNATUREDATE

GOGEBIC COUNTY ROAD COMMISSION

EMPLOYMENT APPLICATION

EQUAL OPPORTUNITY EMPLOYER

APPLICATION IS REQUIRED, resumes are encouraged, but are not a substitute for the application. Submit application to GCRC, 200 North Moore Street, Courthouse Annex, Bessemer, MI 49911.

POSTION FOR WHICH YOU ARE APPLYING

JOB TITLE: ______

ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE JOB YOU ARE APPLYING FOR, WITH OR WITHOUT REASONABLE ACCOMODATION? YES NO

WILL ACCEPT:

_____ PART-TIME

_____ FULL-TIME

_____ TEMPORARY DATE AVAILABLE: ______

PERSONAL INFORMATION

NAME: ______

(LAST)(FIRST)(MIDDLE)

MAILING ADDRESS: ______

(STREET) (CITY) (STATE & ZIP CODE)

DATE OF BIRTH: ______SOCIAL SECURITY NUMBER: ______

DRIVERS LICENSE NUMBER: ______TYPE: ______EXPIRATION DATE: ______

HOME PHONE NUMBER: ______CELL PHONE NUMBER: ______

DATES OF RESIDENCY DURING THE LAST THREE (3) YEARS:

DATES / ADDRESS

HAVE YOU EVER BEEN DISMISSED FROM EMPLOYMENT OR RESIGNED YOUR EMPLOYMENT IN LIEU OF DISMISSAL?

YESNO

IF YES, PLEASE EXPLAIN: ______

EDUCATION AND TRAINING

HIGH SCHOOL GRADUATE OR GENERAL EDUCATION (GED) TEST PASSED? YES NO
IF NO, LIST HIGHEST GRADE COMPLETED:
NAME OF SCHOOL / LOCATION / COURSE OF STUDY / DEGREE OR CERTIFICATE RECEIVED
TRADE SCHOOL OR SPECIAL TRAINING
TRADE SCHOOL OR SPECIAL TRAINING

LICENSURE OR REGISTRATION (EXAMPLES: CDL, PE, CPA, ETC.)

LICENSURE OR REGISTRATION / NUMBER / DATE RECEIVED / EXPIRATION DATE / STATE LICENSING AGENCY

DRIVING EXPERIENCE

CLASS OF EQUIPMENT / TYPE OF EQUIPMENT
(VAN, TANK, FLAT, ETC.) / DATES
FROM TO / APROXIMATE NUMBER OF MILES (TOTAL)
STRAIGHT TRUCK
TRACTOR AND SEMI TRACTOR
TRACTOR – TWO TRAILERS
OTHER
OTHER
OTHER

TRAFFIC RECORD

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST THREE (3) YEARS (OTHER THAN PARKING VIOLATIONS)

DATE CONVICTED / VIOLATION / STATE OF VIOLOATION / PENALTY

HAVE YOU EVER BEEN DENIED A LICENSE, PERMIT, OR PRIVILEGE TO OPERATE A MOTOR VEHICLE? YES NO

IF YES, PLEASE EXPLAIN: ______

HAS ANY LICENSE, PERMIT, OR PRIVILAGE EVER BEEN SUSPENDED OR REVOKED? YES NO

IF YES, PLEASE EXPLAIN: ______

PERIODS OF EMPLOYMENT

DESCRIBE YOUR WORK EXPERIENCE IN DETAIL, BEGINNING WITH YOUR CURRENT OR MOST RECENT JOB. INCLUDE JOB RELATED VOLUNTEER WORK, IF APPLICABLE, AND INDICATED NUMBER OF EMPLOYEES SUPERVISED. USE A SEPARATE BLOCK TO DESCRIBE EACH POSITION. IF NEEDED, ATTACH ADDITIONAL SHEETS, USING SAME FORMAT AS THE APPLICATION. RESUMES MAY BE ATTACHED TO PROVIDE ADDITIONAL INFORMATION.

NAME OF PRESENT OR LAST EMPLOYER: ______

ADDRESS: ______PHONE NUMBER: ______

POSITION HELD: ______FROM ______TO ______

DUTIES & RESPONSIBILITIES: ______

______

RESON FOR LEAVING: ______SUPERVISOR’S NAME: ______

MAY WE CONTACT THIS EMPLOYER? YESNO

NAME OF PRESENT OR LAST EMPLOYER: ______

ADDRESS: ______PHONE NUMBER: ______

POSITION HELD: ______FROM ______TO ______

DUTIES & RESPONSIBILITIES: ______

______

RESON FOR LEAVING: ______SUPERVISOR’S NAME: ______

MAY WE CONTACT THIS EMPLOYER? YESNO

NAME OF PRESENT OR LAST EMPLOYER: ______

ADDRESS: ______PHONE NUMBER: ______

POSITION HELD: ______FROM ______TO ______

DUTIES & RESPONSIBILITIES: ______

______

RESON FOR LEAVING: ______SUPERVISOR’S NAME: ______

MAY WE CONTACT THIS EMPLOYER? YESNO

THIS CERTIFIES THAT I COMPLETED THIS APPLICATION, AND THAT ALL ENTRIES ON IT AND INFORMATION IN IT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

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APPLICANT SIGNATUREDATE

GOGEBIC COUNTY ROAD COMMISSION

200 NORTH MOORE STREET

COURTHOUSE ANNEX

BESSEMER, MI 49911

APPLICANT NAME: ______DATE OF APPLICATION: ______

(PRINT NAME)

IN COMPLIANCE WITH FEDERAL AND STATE EQUAL EMPLOYMENT OPPORTUNITY LAWS, QUALIFIED APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, AGE, MARITAL STATUS, VETERAN STATUS, NON-JOB RELATED DISABILITY, OR ANY OTHER PROTECTED GROUP STATUS.

TO BE READ AND SIGNED BY APPLICANT

I AUTHORIZE YOU TO MAKE SUCH INVESTIGATIONS AND INQUIRIES OF MY PERSONAL, EMPLOYMENT, FINANCIAL OR MEDICAL HISTORY AND OTHER RELATED MATTERS AS MAY BE NECESSARY IN ARRIVING AT AN EMPLOYMENT DECISION. (GENERALLY, INQUIRIES REGARDING MEDICAL HISTORY WILL BE MADE ONLY IF AND AFTER A CONDITIONAL OFFER OF EMPLOYMENT HAS BEEN EXTENDED.)

I HEREBY RELEASE EMPLOYERS, SCHOOLS, HEALTH CARE PROVIDERS AND OTHER PERSONS FROM ALL LIABILITY IN RESPONDING TO INQUIRIES AND RELEASING INFORMATION IN CONNECTION WITH MY APPLICATION.

IN THE EVEN OF EMPLOYMENT, I UNDERSTAND ALSO, THAT I AM REQUIRED TO ABIDE BY ALL RULES AND REGULATIONS OF THE GOGEBIC COUNTY ROAD COMMISSION.

I UNDERSTAND THAT INFORMATION I PROVIDE REGARDING CURRENT AND/OR PREVIOUS EMPLOYERS MAY BE USED, AND THOSE EMPLOYER(S) WILL BE CONTACTED, FOR THE PURPOSE OF INVESTIGATION MY SAFETY PERFORMANCE HISTORY AS REQUIRED BY 49 CFR 391.23(d) AND (e). I UNDERSTAND THAT I HAVE THE RIGHT TO:

*REVIEW INFORMATION PROVIDED BY PREVIOUS EMPLOYERS;

*HAVE ERRORS IN THE INFORMATION CORRECTED BY PREVIOUS EMPLOYERS AND FOR THOSE PREVIOUS

EMPLOYERS TO RE-SEND THE CORRECTED INFORMATION TO THE PROSPECTIVE EMPLOYER;

*HAVE A REBUTTAL STATEMENT ATTACHED TO THE ALLEGED ERRONEOUS INFORMATION, IF THE PREVIOUS

EMPLOYER(S) AND I CANNOT AGREE ON THE ACCURACY OF THE INFORMATION.

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APPLICANT SIGNATUREDATE

FOR COMPANY USE ONLY

PROCESS RECORDS

APPLICANT HIRED ______REJECTED ______

DATE EMPLOYED ______POINT EMPLOYED ______

DEPARTMENT ______CLASSIFICATION ______

(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

SIGNATURE OF INTERVIEWING OFFICER ______

TERMINATION OF EMPLOYMENT

DATE TERMINATED ______DEPARTMENT RELEASED FROM ______

DISMISSED ______VOLUNTARILY OUT ______OTHER ______

TERMINATION REPORT PLACED IN FILE ______SUPERIVISOR ______