<?= $title ?>

“;
print ““;
}

function display_form($errors)
{
if ($_POST)
extract($_POST);
?>

INSTRUCTIONS To the Applicant: We appreciate your interest in the South East Regional Emergency Services Authority and assure
you that we are interested in your qualifications. A clear understanding of your background and work history will aid us in the
application process. Your application must be filled out completely with no blanks for proper processing. We recommend a completed
application accompanied with a proper resume and cover letter attached.

We are an equal opportunity employer and shall consider qualified applicants for all positions without regard to race, color, sex, religion,
national origin, age, height, weight, familial, marital or veteran status, or handicap. Incomplete applications may not be considered.

$errors

“;
?>

Preferred Orientation Date:
/>
11/9/2017
/>
11/10/2017

PERSONAL

Name:

(Last)

(First)

(Middle)

Address:

City/State/Zip:

Home Phone:

Day Time Phone:

(Between 8 am-4 pm, M-F)

Email Address:

(SERESA will be communicating with you via email as to your status in the hiring process.)

Last 4 digits of Social Security Number: />Yes
/>No
Are you authorized to work in the United States?
/>Yes
/>No

Have you been previously employed by SERESA or any of the Jurisdictions that SERESA serves?
/>Yes
/>No

If so, what agency and dates(s):

What positions have you worked?

Supervisor’s Name:

/>Yes
/>No
If yes, what are the dates(s):
/>Yes
/>No
If so, please provide name and explanation:

EMPLOYMENT

Position(s) applied for:
/>Full-time
/>Part-time
/>Other:
Salary Desired:

Date Available to Work:

MILITARY SERVICE RECORD

Have you had any experience in the Armed Forces of the United States or in a State National Guard?
/>Yes
/>No

If yes, what branch?

Rank at discharge:

Date of Discharge:

Did you receive an Honorable Discharge?

Are you in the Reserves?
/>Yes
/>No

If yes, date obligation ends:

Special/Technical Training:

EMPLOYMENT EXPERIEMCE
(List current or most recent job first- past 8 years minimum).

Employer:

Address:

Phone Number:

Job Title:

Supervisor:

Work Performed/Duties:

Employment Dates:

From:

To:

Hourly Rate/Salary:

Beginning:

Ending:

Reason for leaving:

Employer:

Address:

Phone Number:

Job Title:

Supervisor:

Work Performed/Duties:

Employment Dates:

From:

To:

Hourly Rate/Salary:

Beginning:

Ending:

Reason for leaving:

Employer:

Address:

Phone Number:

Job Title:

Supervisor:

Work Performed/Duties:

Employment Dates:

From:

To:

Hourly Rate/Salary:

Beginning:

Ending:

Reason for leaving:

Employer:

Address:

Phone Number:

Job Title:

Supervisor:

Work Performed/Duties:

Employment Dates:

From:

To:

Hourly Rate/Salary:

Beginning:

Ending:

Reason for leaving:

Employer:

Address:

Phone Number:

Job Title:

Supervisor:

Work Performed/Duties:

Employment Dates:

From:

To:

Hourly Rate/Salary:

Beginning:

Ending:

Reason for leaving:

OTHER DISPATCH, LAW OR FIRE AGENCIES to which you have applied.

Name of Agency

Location

Year
Applied

Present Hiring/
Employment Status

EDUCATION

Type	Name/Location (Address, City, State)	Years Completed	Diploma/ Degree	Course of Study
Elementary	<?= $txtSchool1NameAddr ?>	<?= $txtSchool1Years ?>	<?= $txtSchool1Degree ?>	<?= $txtSchool1Study ?>
Middle/Junior High School	<?= $txtSchool2NameAddr ?>	<?= $txtSchool2Years ?>	<?= $txtSchool2Degree ?>	<?= $txtSchool2Study ?>
High School	<?= $txtSchool3NameAddr ?>	<?= $txtSchool3Years ?>	<?= $txtSchool3Degree ?>	<?= $txtSchool3Study ?>
College	<?= $txtSchool4NameAddr ?>	<?= $txtSchool4Years ?>	<?= $txtSchool4Degree ?>	<?= $txtSchool4Study ?>
Graduate	<?= $txtSchool5NameAddr ?>	<?= $txtSchool5Years ?>	<?= $txtSchool5Degree ?>	<?= $txtSchool5Study ?>
Vocational School	<?= $txtSchool6NameAddr ?>	<?= $txtSchool6Years ?>	<?= $txtSchool6Degree ?>	<?= $txtSchool6Study ?>
Other (Specify)	<?= $txtSchool7NameAddr ?>	<?= $txtSchool7Years ?>	<?= $txtSchool7Degree ?>	<?= $txtSchool7Study ?>
Other (Specify)	<?= $txtSchool8NameAddr ?>	<?= $txtSchool8Years ?>	<?= $txtSchool8Degree ?>	<?= $txtSchool8Study ?>
Other (Specify)	<?= $txtSchool9NameAddr ?>	<?= $txtSchool9Years ?>	<?= $txtSchool9Degree ?>	<?= $txtSchool9Study ?>

REFERENCES
Do not include relatives or former employers. Include at least two (2) peer references (must be within five years of your age)

By entering your name in the box below, you are providing your signature to this document and all agreements included within and affirming your identity.

Signature: $txtSignature
Date: “.date(“m/d/Y”).”

“;

if (!$rblOrientation)
$errMsg .= “- Please select Preferred Orientation Date
“;
if (!$txtLast)
$errMsg .= “- Please enter Last Name
“;
if (!$txtFirst)
$errMsg .= “- Please enter First Name
“;
if (!$txtLast4)
$errMsg .= “- Please enter Last 4 of SSN
“;
if (!$chkAcknowledge)
$errMsg .= “- You must acknowledge that you have read the terms and conditions
“;
if (!$chkAuthorize)
$errMsg .= “- You must authorize to release information
“;
if (!$txtSignature)
$errMsg .= “- Please enter your Signature
“;

$errFile = “”;
if (isset($_FILES[‘fileUpload’]))
{
$file_name = $_FILES[‘fileUpload’][‘name’];
$file_size = $_FILES[‘fileUpload’][‘size’];
$file_tmp = $_FILES[‘fileUpload’][‘tmp_name’];
$file_type = $_FILES[‘fileUpload’][‘type’];
$file_ext = strtolower(end(explode(‘.’,$_FILES[‘fileUpload’][‘name’])));

if ($file_name)
{
$extensions = array(“pdf”,”doc”,”docx”);

if (in_array($file_ext, $extensions) === false)
{
$errFile .= “- File not allowed, please choose a PDF or Word file
“;
}

if ($file_size > 2097152)
{
$errFile .= “- File size must be less than 2 MB
“;
}

if (!$errFile)
{
move_uploaded_file($file_tmp, “apps/”.$file_name);
$uplFile = “apps/”.$file_name;
}
else
{
$errMsg .= $errFile;
}
}
}

if (!$errMsg)
{
$strDateTime = date(ymdhi);
$filename = “apps/”.$txtLast.substr($txtFirst,0,1).”_”.$strDateTime.”.html”;
file_put_contents($filename, $strHTML);

$files = array();
$files[] = $filename;
if ($uplFile)
{
$files[] = $uplFile;
}

$to = “seresasupervisors@seresa.org”;
if ($txtEmail)
{
$from = $txtEmail;
}
else
{
$from = “webmaster@seresa.org”;
}
$subject =”Job Application Submitted”;
$message = “A Job Application has been submitted via the website. Attachments are enclosed.”;
$headers = “From: $from”;

$semi_rand = md5(time());
$mime_boundary = “==Multipart_Boundary_x{$semi_rand}x”;
$headers .= “\nMIME-Version: 1.0\n” . “Content-Type: multipart/mixed;\n” . ” boundary=\”{$mime_boundary}\””;
$message = “This is a multi-part message in MIME format.\n\n” . “–{$mime_boundary}\n” . “Content-Type: text/plain; charset=\”iso-8859-1\”\n” . “Content-Transfer-Encoding: 7bit\n\n” . $message . “\n\n”;
$message .= “–{$mime_boundary}\n”;

for ($x=0; $x“;
print “

Application Submitted

“;
print “

Thank you, your application has been successfully submitted.

“;
print “

“;
do_footer();
}
}
if (isset($_POST[‘cancel’]))
{
header(“Location: employment.htm”);
}
}
// Do following whether button pressed or not

$title = ‘SERESA – Job Application’;
do_app_header($title);
print “

“;

display_form($result);
print “

“;
do_app_footer();
?>

Name

Address

Telephone
Number

Years
Known

ADDITIONAL INFORMATION

Have you been convicted of a crime?
/>Yes
/>No
If so, where, when and nature of offense:
/>Yes
/>No
If so, where, when and nature of offense:
/>Yes
/>No
If Yes, please list the type and circumstance. (Answering “Yes” to this question is not an automatic disqualifier for a job with this agency)
/>Yes
/>No
License Number:

AUTHORIZATION AND
UNDERSTANDING

RELEASE OF PRIOR PERSONNEL
RECORDS

BY SIGNING THIS APPLICATION, I AGREE THAT ALL OF THE INFORMATION NOW OR
LATER GIVEN BY ME IN SUPPORT OF MY application for employment is true and complete. I
understand that you may verify any of the information concerning my employment, education, credit or
medical history with the appropriate individuals, organizations, or governmental agencies. I give these
individuals, organizations, or governmental agencies my permission to release any information that you
need, including my previous disciplinary record, without requiring them to contact me or give me written
notice before revealing the information to you. I understand that no verification of my credit history or
request for a “consumer report” under the Fair Credit Reporting Act may be undertaken by you without
my express written authorization in a separate document. By signing this application, and in the case of
a consumer report under the Fair Credit Reporting Act, should I sign the separate Authorization for credit
reports on me, I release you and them from any liability whatsoever arising out of any information request
or disclosure. I agree that any false information in support of my application may subject me to discharge
at any time during my employment.

AT-WILL EMPLOYMENT
STATUS

I AGREE THAT FOR Supervision and Probationary Employee Status, EITHER PARTY MAY
TERMINATE THE EMPLOYMENT RELATIONSHIP, WITH OR WITHOUT CAUSE, AT ANY
TIME, FOR ANY REASON, AND I FURTHER AGREE THAT THIS ARRANGEMENT MAY
ONLY BE CHANGED BY THE Director OF South East Regional Emergency Services Authority (SERESA),
IN WRITING, DIRECTED TO ME PERSONALLY, AND SIGNED BY THE Director. I agree that I shall
be bound by the other rules, policies, regulations, and terms and conditions of employment of SERESA as
they are from time to time changed and that no additional obligations can be imposed by me on SERESA
except those which have been acknowledged, in writing, by the Director or his/her designated
representative. I further agree that my employment is conditional upon satisfactory completion of
documentation as required by the Immigration Reform and Control Act of 1986 and until such time as the
results of my pre-employment physical (if such physical is required) are known.

Handicap Accommodation Request

I UNDERSTAND THAT MICHIGAN LAW REQUIRES EMPLOYERS TO MAKE
ACCOMMODATIONS TO HANDICAPPED APPLICANTS AND EMPLOYEES
WHERE THE ACCOMMODATION DOES NOT IMPOSE AN UNDUE HARDSHIP ON
THE EMPLOYER. I further understand handicapped employees and applicants may request
an accommodation of their handicap by notifying SERESA in writing of the need for
accommodation within 182 days of the date the handicapper knows or should know that an
accommodation is needed. Failure to properly notify SERESA will preclude any claim
that the employer failed to accommodate the handicapper under Michigan law.

/>I acknowledge that I have read the above statements and agree to its terms and conditions

AUTHORIZATION TO RELEASE INFORMATION

We appreciate your interest in employment opportunities with SERESA. As part of our
normal procedure during the pre-employment process, we may perform a routine inquiry into your
background based on the information you have provided us. In order for such information to be
released, we need your concurrence. Therefore, please read the following statement carefully and
indicate your agreement by signing below.

TO WHOM IT MAY CONCERN:

I hereby authorize the South East Regional Emergency Services Authority (the “Employer”),
or other authorized representative of the Employer, within one (1) year from the date hereof, to
obtain any information in your files pertaining to my employment, military record, credit record,
law enforcement record, medical or educational records, including, but not limited to, academic,
achievement, attendance, criminal, personal history and disciplinary records. I hereby direct you
to release such information upon request of the Employer or its authorized representative. I
hereby release the Employer and any authorized representative, as custodian of such records, and
any school, college, university, or other educational institution; hospital, or other repository of
medical records; credit bureau; law enforcement agency; lending institution; consumer reporting
agency; or other business establishment, including its officers, employees, or related personnel, both
individually and collectively, from any and all liability for damages whatsoever, which may at
any time result to me, my heirs, family or associates because of the Employer’s request for and/or
review of records described in this Authorization to Release Information. Should there be any
questions as to the validity of this Release, you may contact me as indicated below.

If you would like to attach a resume, you may send a PDF or Word Document file below:

By entering your name in the box below, you are providing your signature to this document and all agreements included within and affirming your identity.

Signature:

<?= $title ?>

Preferred Orientation Date: $rblOrientation

PERSONAL

Name:

$txtLast

$txtFirst

$txtMiddle

(Last)

(First)

(Middle)

Address:

$txtAddress

City/State/Zip:

$txtCity, $txtState $txtZip

Home Phone:

$txtHomePhone	Day Time Phone:	$txtDayPhone
	(Between 8 am-4 pm, M-F)

Email Address:

$txtEmail

(SERESA will be communicating with you via email as to your status in the hiring process.)

Last 4 digits of Social Security Number: $txtLast4

Are you 18 years of age or older?
$rblAge18
Are you authorized to work in the United States?
$rblWorkUS

Have you been previously employed by SERESA or any of the Jurisdictions that SERESA serves? $rblSERESAEmp
If so, what agency and dates(s):	$txtPrevAgencies
What positions have you worked?	$txtPrevPositions
Supervisor’s Name:	$txtSupervisor

Have you filed an application with SERESA before?
$rblPrevApply
If yes, what are the dates(s):
$txtPrevApplyDates

List any relatives or friends working for SERESA or any of the Jurisdictions that SERESA dispatches for here:
$txtFamilyFriends

In order to check and verify your work record, have you ever been known by another name?
$rblPrevName
If so, please provide name and explanation:
$txtPrevName

EMPLOYMENT

Position(s) applied for:
$txtPositionsApplied

Kind of Work Sought:
$rblWorkSought
$txtWorkSought
If part-time, please specify hours and days desired:
$txtHoursDesired

Salary Desired:

$txtSalaryDesired

Date Available to Work:

$txtDateAvailable

How did you hear about this position?
$txtHowHeard

MILITARY SERVICE RECORD

Have you had any experience in the Armed Forces of the United States or in a State National Guard?
$rblMilitary

If yes, what branch?

$txtBranch

Rank at discharge:

$txtRank

Date of Discharge:

$txtDischargeDate

Did you receive an Honorable Discharge?

$txtHonorableDischarge

Are you in the Reserves?
$rblReserves

If yes, date obligation ends:

$txtReservesEnd

Special/Technical Training:

$txtSpecialTraining

EMPLOYMENT EXPERIEMCE
(List current or most recent job first- past 8 years minimum).

Employer:
$txtEmp1Name

Address:
$txtEmp1Addr

Phone Number:
$txtEmp1Phone

Job Title:
$txtEmp1Title

Supervisor:
$txtEmp1Supv

Work Performed/Duties:
$txtEmp1Duties

Employment Dates:

From:	$txtEmp1From
To:	$txtEmp1To

Hourly Rate/Salary:

Beginning:	$txtEmp1BegSal
Ending:	$txtEmp1EndSal

Reason for leaving:
$txtEmp1Reason

Employer:
$txtEmp2Name

Address:
$txtEmp2Addr

Phone Number:
$txtEmp2Phone

Job Title:
$txtEmp2Title

Supervisor:
$txtEmp2Supv

Work Performed/Duties:
$txtEmp2Duties

Employment Dates:

From:	$txtEmp2From
To:	$txtEmp2To

Hourly Rate/Salary:

Beginning:	$txtEmp2BegSal
Ending:	$txtEmp2EndSal

Reason for leaving:
$txtEmp2Reason

Employer:
$txtEmp3Name

Address:
$txtEmp3Addr

Phone Number:
$txtEmp3Phone

Job Title:
$txtEmp3Title

Supervisor:
$txtEmp3Supv

Work Performed/Duties:
$txtEmp3Duties

Employment Dates:

From:	$txtEmp3From
To:	$txtEmp3To

Hourly Rate/Salary:

Beginning:	$txtEmp3BegSal
Ending:	$txtEmp3EndSal

Reason for leaving:
$txtEmp3Reason

Employer:
$txtEmp4Name

Address:
$txtEmp4Addr

Phone Number:
$txtEmp4Phone

Job Title:
$txtEmp4Title

Supervisor:
$txtEmp4Supv

Work Performed/Duties:
$txtEmp4Duties

Employment Dates:

From:	$txtEmp4From
To:	$txtEmp4To

Hourly Rate/Salary:

Beginning:	$txtEmp4BegSal
Ending:	$txtEmp4EndSal

Reason for leaving:
$txtEmp4Reason

Employer:
$txtEmp5Name

Address:
$txtEmp5Addr

Phone Number:
$txtEmp5Phone

Job Title:
$txtEmp5Title

Supervisor:
$txtEmp5Supv

Work Performed/Duties:
$txtEmp5Duties

Employment Dates:

From:	$txtEmp5From
To:	$txtEmp5To

Hourly Rate/Salary:

Beginning:	$txtEmp5BegSal
Ending:	$txtEmp5EndSal

Reason for leaving:
$txtEmp5Reason

OTHER DISPATCH, LAW OR FIRE AGENCIES to which you have applied.

Name of Agency	Location	Year Applied	Present Hiring/ Employment Status
$txtAgency1Name	$txtAgency1Location	$txtAgency1YearApplied	$txtAgency1Status
$txtAgency2Name	$txtAgency2Location	$txtAgency2YearApplied	$txtAgency2Status
$txtAgency3Name	$txtAgency3Location	$txtAgency3YearApplied	$txtAgency3Status
$txtAgency4Name	$txtAgency4Location	$txtAgency4YearApplied	$txtAgency4Status
$txtAgency5Name	$txtAgency5Location	$txtAgency5YearApplied	$txtAgency5Status
$txtAgency6Name	$txtAgency6Location	$txtAgency6YearApplied	$txtAgency6Status

EDUCATION

Type	Name/Location (Address, City, State)	Years Completed	Diploma/ Degree	Course of Study
Elementary	$txtSchool1NameAddr	$txtSchool1Years	$txtSchool1Degree	$txtSchool1Study
Middle/Junior High School	$txtSchool2NameAddr	$txtSchool2Years	$txtSchool2Degree	$txtSchool2Study
High School	$txtSchool3NameAddr	$txtSchool3Years	$txtSchool3Degree	$txtSchool3Study
College	$txtSchool4NameAddr	$txtSchool4Years	$txtSchool4Degree	$txtSchool4Study
Graduate	$txtSchool5NameAddr	$txtSchool5Years	$txtSchool5Degree	$txtSchool5Study
Vocational School	$txtSchool6NameAddr	$txtSchool6Years	$txtSchool6Degree	$txtSchool6Study
Other (Specify)	$txtSchool7NameAddr	$txtSchool7Years	$txtSchool7Degree	$txtSchool7Study
Other (Specify)	$txtSchool8NameAddr	$txtSchool8Years	$txtSchool8Degree	$txtSchool8Study
Other (Specify)	$txtSchool9NameAddr	$txtSchool9Years	$txtSchool9Degree	$txtSchool9Study

REFERENCES
Do not include relatives or former employers. Include at least two (2) peer references (must be within five years of your age)

Name	Address	Telephone Number	Years Known
1	$txtRef1Name	$txtRef1Addr	$txtRef1Phone	$txtRef1Known
2	$txtRef2Name	$txtRef2Addr	$txtRef2Phone	$txtRef2Known
3	$txtRef3Name	$txtRef3Addr	$txtRef3Phone	$txtRef3Known
4	$txtRef4Name	$txtRef4Addr	$txtRef4Phone	$txtRef4Known

ADDITIONAL INFORMATION

Have you been convicted of a crime?
$rblConvicted
If so, where, when and nature of offense:
$txtConvicted

Do you have any criminal charges pending against you?
$rblPending
If so, where, when and nature of offense:
$txtPending

Have you used any illegal substances within the last six months?
$rblDrugs
If Yes, please list the type and circumstance. (Answering “Yes” to this question is not an automatic disqualifier for a job with this agency)
$txtDrugs

Do you have a valid driver’s license?
$rblLicense
License Number:
$txtLicenseNbr
State:
$txtLicenseState

List the social media sites you belong to:
$txtSocial

State any additional information that you feel may be helpful to us in considering your application:
$txtOtherInfo

AUTHORIZATION AND
UNDERSTANDING

RELEASE OF PRIOR PERSONNEL
RECORDS

BY SIGNING THIS APPLICATION, I AGREE THAT ALL OF THE INFORMATION NOW OR
LATER GIVEN BY ME IN SUPPORT OF MY application for employment is true and complete. I
understand that you may verify any of the information concerning my employment, education, credit or
medical history with the appropriate individuals, organizations, or governmental agencies. I give these
individuals, organizations, or governmental agencies my permission to release any information that you
need, including my previous disciplinary record, without requiring them to contact me or give me written
notice before revealing the information to you. I understand that no verification of my credit history or
request for a \”consumer report\” under the Fair Credit Reporting Act may be undertaken by you without
my express written authorization in a separate document. By signing this application, and in the case of
a consumer report under the Fair Credit Reporting Act, should I sign the separate Authorization for credit
reports on me, I release you and them from any liability whatsoever arising out of any information request
or disclosure. I agree that any false information in support of my application may subject me to discharge
at any time during my employment.

AT-WILL EMPLOYMENT
STATUS

Handicap Accommodation Request

AUTHORIZATION TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

I hereby authorize the South East Regional Emergency Services Authority (the \”Employer\”),
or other authorized representative of the Employer, within one (1) year from the date hereof, to
obtain any information in your files pertaining to my employment, military record, credit record,
law enforcement record, medical or educational records, including, but not limited to, academic,
achievement, attendance, criminal, personal history and disciplinary records. I hereby direct you
to release such information upon request of the Employer or its authorized representative. I
hereby release the Employer and any authorized representative, as custodian of such records, and
any school, college, university, or other educational institution; hospital, or other repository of
medical records; credit bureau; law enforcement agency; lending institution; consumer reporting
agency; or other business establishment, including its officers, employees, or related personnel, both
individually and collectively, from any and all liability for damages whatsoever, which may at
any time result to me, my heirs, family or associates because of the Employer’s request for and/or
review of records described in this Authorization to Release Information. Should there be any
questions as to the validity of this Release, you may contact me as indicated below.

Application Submitted

MISSION STATEMENT

CONTACT US