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GOOCHLAND-POWHATAN

COMMUNITY SERVICES

An Equal Opportunity Employer

Application for Employment

Please return app to:

P.O. Box 189

Goochland, VA 23063

804-***-****

Fax: 556-5407

Employees of the Goochland-Powhatan Community Services and applicants for employment shall be afforded equal opportunity in all aspects of employment without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender or age.

As a means of accommodation to persons with specific disabilities that prevent them from completing this application, confidential assistance in filling out this application may be obtained by calling Goochland- Powhatan Community Services at 804-***-****.

1. Position applied for

(one per application) 2. Location

3. Social Security No.

Note: Completion of number three is optional. Failure to submit social security number on this form will not prohibit employment consideration. Social security number may be required on other forms prior to employment.) 4. Full legal name 6. Home Phone

Last First Middle

7. Business Phone

5. Address

8. Cell Phone

Street City State Zip

9. Email Address:

10. EDUCATION

A. Check Highest Grade Completed 1 2 3 4 5 6 7 8 9 10 11 12 B. If you did not complete high school, do you have a high school equivalency diploma? Yes No C. Check number of years of post high school education. 1 2 3 4 5 6 7 D. Name and Location of Institution Degree Received Major or Specialty Minor Dates Attended E. If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date: 11. EXPERIENCE – Use supplementary experience form(s) for additional space. Starting with the most recent, describe ALL paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position. You may list significantly different jobs within the same organization as separate items. May we contact your present supervisor? Yes No

Job Title: Duties:

Employer:

Address:

Phone:

Type of

business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: mo/yr To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present Job Title: Duties:

Employer:

Address:

Phone:

Type of

business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: mo/yr To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present Job Title: Duties:

Employer:

Address:

Phone:

Type of

business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: mo/yr To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present 12. ADDITIONAL INFORMATION – Use this space for any additional information you think would help us evaluate your application including training, seminars, workshops, special achievements and specialized skills: 13. WORD PROCESSING – Word processing equipment/programs used: 14. LICENSE (to include driver’s), certificates or other authorizations to practice a trade or profession. – Type License Number Granted by (licensing board)

15. REFERENCES – List names, addresses and relationships of three persons not related to you who know your qualifications: Name Address Phone Relationship

16. MISCELLANEOUS –

A. Check which shift you will accept: Day Evening Night Rotating Weekends Specify shift hours B. Check which job status you would accept: Full-time Part-time (specify) C. Check which employment status you’d accept: Salaried (benefits) Hourly (No benefits) Part-time salaried (leave benefits only) D. Are you willing to accept employment

which requires you to travel? No Yes. If yes, During the day only Occasionally overnight Frequently overnight. E. List the geographic locations in which you are willing to work. If anywhere in Virginia, write “all” F. For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States? Yes No. Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to that effect should you be employed. G. Are you willing to provide your own transportation if necessary for your employment? Yes No. H. Section 2.1-32.1 of the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality of the Commonwealth from employing a person who is required to present himself and submit to the federal Selective Service registration requirement and failed to do so. If you are/were required to register for the Selective Service, have you done so? Yes No. If no, state reason: I. For purposes of compliance with Section 2.1-112 of the Code of Virginia, are you a veteran who received an honorable discharge and served more than 180 consecutive days of full-time active duty in the US Army, Navy, Air Force, Marines, or reserve components thereof, including the National Guard? Yes No. If yes, did you serve during the Vietnam Conflict (2/28/61-3/7/75)? Yes No J. Have you ever been convicted* for any violation(s) of law, including moving traffic violations. Yes No If YES, please provide the following: Description of offense:

Statute or ordinance(if known ): Date of Charge: Date of Conviction: County, City, State of Conviction:

(For additional convictions use plain paper. Include all information listed above.)

*Convictions include Virginia juvenile adjudications for Capital Murder, First and Second Degree Murder, Lynching, or Aggravated Malicious Wounding, if you were age fourteen (14) to eighteen (18) when charged.

17. AVAILABILITY - When will you be available to start work? (No date is necessary if you are available as soon as you give two (2) weeks notice.) Month Date Year

18. CERTIFICATION--Each Application Requires Current Date and Original Signature I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment in the service of Goochland-Powhatan Community Services. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent to references and former employers and educational institutions listed being contacted regarding this application. I further authorize Goochland-Powhatan Community Services to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as determined by the agency head or designee. Applicant Signature Date

Pursuant to federal regulations, we collect responses to the questions below for record keeping purposes. This information will NOT be kept with your application for employment. Federal law prohibits unlawful discrimination on the basis of race, color, sex, age, national origin, religion, or disability. Check the block for the racial or ethnic group with which you identify:

Check the block for the highest level of education you have completed (check only one):

Check the appropriate block:

Female

White (includes Arabian) Less than 8th grade Male

Black (includes Jamaican, Bahamians and Completed 8th grade other Caribbeans of African but not Hispanic Attended high school or Arabian descent) High school graduate or equivalent Please indicate your date of birth: / / Hispanic (includes persons of Mexican, Attended college and/or associate degree Puerto Rican, Central or South American or College graduate Position applied for: other Spanish origin or culture) Attended graduate school Asian & Asian American (includes Pakistanis, Master’s degree Indians & Pacific Islanders) Graduate study beyond master’s American Indians (includes Alaskans) requirements FOR OFFICE USE ONLY Ph.D. or professional degree EEO Category:

SUPPLEMENTARY EXPERIENCE Attachment #

Name: Position Applied For:

Job Title: Duties:

Employer:

Address:

Phone:

Type of business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: mo/yr To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present Job Title: Duties:

Employer:

Address:

Phone:

Type of business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: mo/yr To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present Job Title: Duties:

Employer:

Address:

Phone:

Type of business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: mo/yr To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present SUPPLEMENTARY EXPERIENCE Attachment #

Name: Position Applied For:

Job Title: Duties:

Employer:

Address:

Phone:

Type of business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: mo/yr To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present Job Title: Duties:

Employer:

Address:

Phone:

Type of business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: mo/yr To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present Job Title: Duties:

Employer:

Address:

Phone:

Type of business:

Immediate Supervisor:

Title:

Number and titles of employees you supervised

Salary: Start Finish Equipment Used

Dates: (mo/yr) To Reason for Leaving

Full-time Part-time Hours/Week Your name if different from present

Contact this candidate