Today's Date

Please identify and describe yourself:

First Name
Last Name
Middle Initial
Last 4 Digits Social Security No.
Present Address
City
State
Zip
Phone
Alternative Phone
E-Mail Address

If you are under 18 years of age, can you furnish a work permit?     Yes    No

Are you a citizen of the United States?     Yes    No

Are you a permanent resident of the United States?     Yes    No

If no, please enter your Visa number.

Driver's license and issuing state, if driving is an essential function of position.

Do you have any court-ordered restrictions on your license?   Yes   No

If yes, please explain.

Have you ever been convicted of a crime or are there any felony charges pending against you?   Yes   No

If yes, please provide date(s) and details.

NOTE: Answering "yes" to this question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken in account.

Are you able to perform the essential duties of the position for which you are applying, with or without accommodation?

Do you have friends and/or family who are currently working at YCUA?   Yes   No

If yes, list names:

Employment Desired:

Position	Clerical   Custodial   Other
Answering An Ad For:
Desired Salary Range (If Applicable):

Are you willing to work weekends and holidays as required?   Yes   No

How did you find out about employment at YCUA?

Education:

Name Of High School
High School City & State
Graduate?	Yes   No

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College
College City & State
Degree / Major
Graduate?	Yes   No

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Trade/Business School
T/B School City & State
Degree / Major
Graduate?	Yes   No

Describe any special skills, training, licenses, and/or certificates that you possess.

If you are currently employed, may we inquire of your present employer? 
Yes    No

Employers (Starting with the most recent):

Name of Employer
Phone Number
Address
Position Held
Salary / Pay Rate
Month / Year From	To
Duties
Reason For Leaving
Supervisor's Name
What notice would be required for your current employer?

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Name of Employer
Phone Number
Address
Position Held
Salary / Pay Rate
Month / Year From	To
Duties
Reason For Leaving
Supervisor's Name

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Name of Employer
Phone Number
Address
Position Held
Salary / Pay Rate
Month / Year From	To
Duties
Reason For Leaving
Supervisor's Name

References (Give the names of three (3) unrelated people):

Name
Address
City	State
Phone

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Name
Address
City	State
Phone

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Name
Address
City	State
Phone

You must live within 20 miles of the City of Ypsilanti, or the Townships of Ypsilanti, Sumpter, Augusta, Superior, Pittsfield, Northville, Plymouth and Canton within 90 days of employment.

By clicking the "SUBMIT FORM" button at the bottom of this page, I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the Authority's rules and regulations, and I agree that I do not know of any health or personal condition that would prevent me from carrying out the duties of the position.

You may also print out a blank employment application form to be faxed or delivered to the Human Resources Director by clicking here.