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3. The City of Rochester is an equal opportunity employer and shall consider all qualified applicants for all positions without regard to race, color, sex, religion, national origin, age, height, weight, marital status, family status, veteran status, physical or mental disability, sexual orientation, gender identity or any other protected category. We provide reasonable accommodation for qualified individuals with a disability if requested.

   Type or print in blue ink. You are required to answer all questions completely, even if you enclose a resume. Extra pages may be attached if you need them. You are responsible for complying with any application deadlines. This form may be turned in at the Human Resources Department, mailed to the above address, faxed to (248) 733-3170, or emailed to HR@rochestermi.org.

5. Position Applied For:
6. Date:
   Date:
8. First Name and Middle Name (required)
9. Last Name
11. Address 1
13. Address 2
15. City
16. State
17. Zip Code
19. Phone Number (Cell or Home):
20. Phone Number (Work):
22. Driver's License # (required):
24. E-mail Address:
26. Note:

    If you are applying for a position within the Police Department, please either call them at 248-651-9621 with your Driver's License number, or fax your Driver's License to 248-963-0799 with a memo indicating the application position.

30. Are You 18 Years of Age or Older?

    1. Yes
    2. No
34. EDUCATION AND TRAINING
36. High School
37. Vocational/Technical (Optional)
39. Did you graduate?

    1. Yes
    2. No
    3. GED
40. Did you graduate?

    1. Yes
    2. No
42. Number of credit hours earned:
43. Number of credit hours earned:
45. Degree/Certificate
46. Degree/Certificate
48. Major/Minor
49. Major/Minor
53. College
54. Graduate School (Optional)
56. Did you graduate?

    1. Yes
    2. No
57. Did you graduate?

    1. Yes
    2. No
59. Number of credit hours earned:
60. Number of credit hours earned:
62. Degree/Certificate
63. Degree/Certificate
65. Major/Minor
66. Major/Minor
68. Describe any specialized training, apprenticeships, internships, skills, licenses, endorsements, certificates, and extracurricular activities that pertain to the position for which you are applying (include CDL licenses and endorsements:
70. List professional, trade, business group memberships and offices held and volunteer work. Exclude the name and character of groups which indicate race, color, sex, religion, national origin, age, height, weight, marital status, family status, veteran status, physical or mental disability, sexual orientation, gender identity or any other protected category:
74. EMPLOYMENT HISTORY
76. Employer
77. Start Date
    Start Date
79. Telephone + Area Code
80. End Date
    End Date
82. Job Title
83. Supervisor
85. Starting Salary/Hourly Rate
86. Ending Salary/Hourly Rate
88. Reason(s) for Leaving
90. Work Performed
92. Employment Status

    1. Full Time
    2. Part Time
96. Employer
97. Start Date
    Start Date
99. Telephone + Area Code
100. End Date
     End Date
102. Job Title
103. Supervisor
105. Starting Salary/Hourly Rate
106. Ending Salary/Hourly Rate
108. Reason(s) for Leaving
110. Work Performed
112. Employment Status

     1. Full Time
     2. Part Time
116. Employer
117. Start Date
     Start Date
119. Telephone + Area Code
120. End Date
     End Date
122. Job Title
123. Supervisor
125. Starting Salary/Hourly Rate
126. Ending Salary/Hourly Rate
128. Reason(s) for Leaving
130. Work Performed
132. Employment Status

     1. Full Time
     2. Part Time
136. Employer
137. Start Date
     Start Date
139. Telephone + Area Code
140. End Date
     End Date
142. Job Title
143. Supervisor
145. Starting Salary/Hourly Rate
146. Ending Salary/Hourly Rate
148. Reason(s) for Leaving
150. Work Performed
152. Employment Status

     1. Full Time
     2. Part Time
156. PROFESSIONAL REFERENCES

     (Do include former employers)

158. Name/Title
159. Email
161. Phone Number
162. Relationship
166. Name/Title
167. Email
169. Phone Number
170. Relationship
174. Name/Title
175. Email
177. Phone Number
178. Relationship
180. Are you a relative by birth or marriage to any City of Rochester employee or elected official?

     1. Yes
     2. No
182. If yes, please list below:
184. When can you start?
     When can you start?
186. What kind of employment are you interested in? Check as many as you like.

     1. Full Time

     1. Part Time

     1. Seasonal

     1. Temporary
190. MILITARY SERVICE RECORD
192. Have you had any experience in the Armed Forces of the United States of America or in a State National Guard?

     1. Yes
     2. No

     (If yes, please attach DD214)

194. If yes, what branch?
195. Rank at discharge?
197. Dates of service:
     Dates of service: Start Date

     —

     Dates of service: End Date
198. Date of discharge:
     Date of discharge:
202. AGREEMENT AND UNDERSTANDING
204. I certify that the information in this application is true, complete and correct to the best of my knowledge and understand that falsification, misleading, misrepresentation, or omission of any information submitted in connection with my application or interview, whether in this document or not, may result in rejection of my application or, if hired, in dismissal.
206. Signature*
207. Today's Date
     Today's Date
209. *By typing/signing your name electronically on this Application you are agreeing that your electronic signature is the legal equivalent of your manual signature.
Leave This Blank:


211. 1. Receive an email copy of this form.
212. Email address

     This field is not part of the form submission.

213. Submit

* indicates a required field