[nfbmi-talk] maybe a job for blind person here?

[joe harcz Comcast]

CHARTER TOWNSHIP OF LANSING
Table with 2 columns and 7 rowsAPPLICATION FOR EMPLOYMENT CAREFUL AND THOUGHTFUL COMPLETION OF THIS APPLICATION IS AN IMPORTANT STEP IN OUR 
CONSIDERATION OF INDIVIDUALS FOR EMPLOYMENT. PLEASE COMPLETE THE ENTIRE APPLICATION. PRINT 
IN INK. ASK FOR AN EXTRA PIECE OF PAPER IF YOU NEED TO CLARIFY ANY RESPONSES. YOUR APPLICATION 
MUST ALSO SPECIFY THE POSITION FOR WHICH YOU ARE APPLYING. STATING THAT YOU WILL DO 
“ANYTHING” IS INDEFINITE AND MAY RESULT IN YOUR APPLICATION NOT BEING ACCEPTED BY THE 
EMPLOYER. YOUR APPLICATION WILL BE CONSIDERED FOR SIXTY (60) DAYS. TODAY’S DATE: TIME: NAME: 
(Last) (First) (Middle) SOC. SEC. # TELEPHONE # CURRENT 
ADDRESS: ________________________________________ LENGTH OF TIM E AT THIS ADDRESS: PREVIOUS 
ADDRESS: _______________________________________ LENGTH OF TIM E AT THIS ADDRESS: Table endTable with 2 columns and 6 rowsJOB(S) APPLIED FOR: 1 
RATE OF PAY EXPECTED: $__________________ PER 2 
RATE OF PAY EXPECTED: $__________________ PER DO YOU W ANT TO W ORK: G FULL-TIM E G PART-TIM E ? If applying only for part-time, 
what days and hours? Have you ever applied for work with us before? G Yes G No 
If yes, when? Do you have any skills, qualifications or experiences which you feel would especially fit you for work with us? Table endTable with 7 columns and 25 rowsU.S. ARMED FORCES SERVICE? G YES G NO Branch: Duties: Rank or rating at 
time of enlistment: Rating at time 
of discharge: Were you dishonorably discharged? G Yes G No 
If yes, explain: Are you able to do the job for which you are applying: G Yes G No 
If not, please explain:____________________________________________________________________________________________________ 
_____________________________________________________________________________________________________________________ Are you 18 years of age or older? G Yes G No Have you ever been convicted of a crime? G Yes G No 
If yes, explain when, where, and the nature of the offense: _______________________________________________________ 
______________________________________________________________________________________________________ 
(Conviction of a crime will not be an automatic bar to employment.) Are you authorized to work in the United States? G Yes G No If hired, when can you start? 
EDUCATION SCHOOL NAME OF SCHOOL # YEARS ATTENDED CITY/STATE COURSE GRAMMAR 



HIGH SCHOOL 



COLLEGE 



OTHER 








PRIOR WORK EXPERIENCE NAME & ADDRESS OF 
EMPLOYER DATES OF EMPLOYMENT REASON FOR LEAVING TYPE OF WORK DONE STARTING 
PAY FINAL PAY 
FROM TO 






































Table endTable with 3 columns and 8 rows



BUSINESS REFERENCES 
NAME ADDRESS/TELEPHONE NUMBER OCCUPATION 












Table endAPPLICANT’S CERTIFICATION AND AGREEMENT 
PLEASE READ CAREFULLY: 
1. Certification of Truthfulness. I certify that all statements on this Application for Employment are made truthfully and 
without evasion, and further understand and agree that such statements may be investigated and, if found to be false, will be 
sufficient reason for not being employed or, if employed, will result in my dismissal. 2. Authorization for Employment/Educational Information. I authorize the references listed on the Application for 
Employment, and any prior employer, educational institution, or any other persons or organizations to give the Charter 
Township of Lansing any and all information, or any other pertinent information, they may have, personal or otherwise, and 
release all parties from all liability for any damage that may result from furnishing any lawful information to the Charter 
Township of Lansing. I hereby waive written notice that employment information is being provided by any person or 
organization. 3. Employment at Will. If I am hired, in consideration of my employment, I agree to abide by the rules and policies of the 
Charter Township of Lansing, including any change made from time to time, and agree that, subject to the provisions of any 
written agreement to the contrary, my employment and compensation can be terminated with or without cause, and with or 
without notice, at any time, at the option of either the Charter Township of Lansing or myself. I understand that no manager 
or other representative of the Charter Township of Lansing, other than the Township Supervisor, has any authority to enter into 
any agreement for employment for any specific or indefinite period of time, or to make any agreement contrary to the foregoing. 
Any such agreement made by the Township Supervisor must be made in writing to be effective. 4. Authorization to Work. If I am selected for hire, I will be offered employment provided I verify that I am authorized to 
work as required by the Immigration Reform and Control Act of 1986. 5.  Need for Accommodation. If I am a person with a disability who requires an accommodation to perform the job, I must 
notify the Charter Township of Lansing of that need within 182 days after I knew or reasonably should have known that an 
accommodation was needed. Failure to do so will bar me under state but not federal law from alleging that the Charter 
Township of Lansing has not accommodated me as required by law. 6. Criminal Records Check. I agree to execute an authorization for the Charter Township of Lansing to secure criminal 
conviction history from the appropriate law enforcement agency should the Charter Township of Lansing determine it is 
necessary to do so. 7. Release of Medical Information. I authorize every medical doctor, physician or other healthcare provider to provide any 
and all information, including but not limited to, all medical reports, laboratory reports, x-rays or clinical abstracts relating to 
my previous health history or employment in connection with any examination, consultation, test or evaluation. I hereby release 
every medical doctor, healthcare personnel and every other person, firm, officer, corporation, association, organization or 
institute which shall comply with the authorization or request made in this respect from any and all liability. I understand that 
I will be asked to sign a HIPAA Disclosure Authorization Form to be sent to my physician and/or other healthcare providers 
once a job offer has been made. 8. Physical Exam and Drug and Alcohol Testing. I agree that if a job offer is made to me I will, before commencing 
employment, take a physical exam and authorize the Charter Township of Lansing or its designated agent(s) to withdraw 
specimen(s) of my blood, urine or hair for chemical analysis. One purpose of this analysis is to determine or exclude the 
presence of alcohol, drugs or other substances. I understand that decisions concerning my employment will be made as a result 
of this test. I further authorize any physician or entity conducting such testing to release the results of such testing to the 
Charter Township of Lansing. 9. Psychological/Physical Testing. If offered employment, I agree to submit to any psychological or physical testing which 
may be necessary to determine my ability to perform the job for which I am being considered. I further authorize any physician 
or entity conducting such medical examination to release the results of such examination to the Charter Township of Lansing. 10. Driving Record Check. If applying for a position that requires driving a Charter Township of Lansing vehicle, I grant 
the Charter Township of Lansing and its agents the authority to make investigations and inquiries of my driving record. 11. Fringe Benefits. In accepting employment with the Charter Township of Lansing, I agree to accept all fringe benefits 
when eligible as provided now or in the future. I understand that it is my responsibility to provide documentation for 
verification of eligibility for fringe benefits as well as information regarding mailing address, telephone numbers or contact 
arrangements, withholding exemptions and dependent information. The Charter Township of Lansing shall rely on the most 
recent information for all purposes. 12. Limitation of Action. I agree that I shall not commence any action or other legal proceeding relating to my employment 
or the termination thereof more than six (6) months after the event complained of, and I voluntarily waive any statute of 
limitations to the contrary. 13. Consideration of Employment. I understand that my Application will be considered pursuant to the Charter Township 
of Lansing’s normal procedures for a period of SIXTY (60) DAYS. IF I AM STILL INTERESTED IN EMPLOYMENT THEREAFTER, I 
MUST REAPPLY. I HAVE READ AND UNDERSTAND ITEMS #1 THROUGH #13 ABOVE, AND ACKNOWLEDGE THAT WITH MY SIGNATURE BELOW. 
Date Applicant’s Signature