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Russell Co Application
Document Date: Invalid date Document: Russell Co Application.pdf
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COUNTY OF RUSSELL, VIRGINIA BOARD OF SUPERVISORS APPLICATION FOR EMPLOYMENT
ALL INFORMATION OBTAINED IN THIS APPLICATION WILL BE DISSEMINATED ONLY ACCORDING TO THE FEDERAL PRIVACY ACT OF 1976. FEDERAL LAW PROHIBITS DISCRIMINATION BECAUSE OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, OR HANDICAP. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, YOU MAY NOTIFY THE EQUAL EMPLOYMENT OPPORTUNITY COMMISSION. THE COUNTY OF RUSSELL, VIRGINIA RESERVES THE RIGHT TO ACCEPT APPLICATIONS FOR EMPLOYMENT ONLY FOR SPECIFICALLY ADVERTISED POSITIONS. THE COUNTY DEPARTMENT OF HUMAN RESOURCES RETAINS ALL APPLICATIONS RECEIVED FOR ONE (1) YEAR.
APPLICANTS MAY SUBMIT RESUMES CONTAINING THE SAME INFORMATION IN LIEU OF PAGES 2 THROUGH 4 OF THIS APPLICATION. PLEASE COMPLETE AND ATTACH THIS PAGE AS COVER TO THE RESUME.
POSITION APPLIED FOR
OFFICE, DEPARTMENT, OR AGENCY
APPLICANT NAME
APPLICANT CONTACT INFORMATION APPLICANT MAILING ADDRESS:
STATE OF ISSUE:
HOW LONG HAVE YOU LIVED AT THIS ADDRESS: MOS/YR
I THE UNDERSIGNED HEREBY SUBMIT THIS APPLICATION FOR EMPLOYMENT FOR THE POSITION INDICATED HEREON. THE INFORMATION PROVIDED IN THIS APPLICATION FOR EMPLOYMENT AND SUPPORTING DOCUMENTATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT IF EMPLOYED, FALSE STATEMENTS ON THIS APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE CONSIDERED SUFFICIENT CAUSE FOR TERMINATION OF EMPLOYMENT.
I FURTHER HEREBY AUTHORIZE THE RUSSELL COUNTY BOARD OF SUPERVISORS TO INSPECT AND COPY ANY DOCUMENTS, RECORDS AND INFORMATION RELATING TO MY CRIMINAL, TRAFFIC OR CREDIT RECORD. THIS AUTHORIZATION INCLUDES, BUT IS NOT LIMITED TO, AUTHORIZATION TO VERIFY INFORMATION SUBMITTED THROUGH PERSONAL INTERVIEW TO ASSIST IN THE BACKGROUND INVESTIGATION. I HEREBY RELEASE THE COUNTY OF RUSSELL VIRGINIA, ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY AND RESPONSIBILITY ARISING OUT OF THE OBTAINING OR RELEASE OF ANY INFORMATION CONCERNING ME IN CONNECTION WITH THIS BACKGROUND INVESTIGATION.
RUSSELL COUNTY PROMOTES A DRUG-FREE WORK ENVIRONMENT. IF A JOB OFFER IS EXTENDED TO YOU, YOU WILL BE REQUIRED TO SUBMIT TO AND PASS A DRUG AND/OR ALCOHOL TEST BEFORE BEGINNING WORK. ADDITIONALLY, A DRUG TEST MAY BE REQUIRED ON A RANDOM BASIS AND FOLLOWING A WORK-RELATED ACCIDENT WITH INJURY OR PROPERTY DAMAGE…
IN CONSIDERATION OF EMPLOYMENT WITH THE COUNTY OF RUSSELL, VIRGINIA, I AGREE TO CONFORM TO THE POLICIES, RULES AND REGULATIONS OF THE COUNTY, AND I UNDERSTAND AND AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF THE COUNTY OR MYSELF. I UNDERSTAND THAT NO OTHER EMPLOYEE HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.
APPLICANT CERTIFICATION & AUTHORIZATION TO RELEASE INFORMATION
APPLICANT GENERAL INFORMATION DO YOU HAVE A VALID DRIVERS LICENSE: YES NO COMMERCIAL DRIVERS LICENSE CLASS: LICENSE NO.: HAVE YOU BEEN EMPLOYED BY RUSSELL COUNTY BEFORE: YES NO IF YES, WHEN AND IN WHAT CAPACITY:
WHAT DATE WOULD YOU BE AVAILABLE TO BEGIN EMPLOYMENT:
AREA CODE & MOBILE TELEPHONEAREA CODE & WORK TELEPHONE
STREET ADDRESS OR P.O. BOX CITY ZIP CODE AREA CODE & HOME TELEPHONE
FIRST, MIDDLE, AND LAST NAME
POSITION TITLE
NOYES
HAVE YOU EVER BEEN DISMISSED FROM EMPLOYMENT OR FORCED TO RESIGN, OR RESIGNED IN ORDER TO AVOID BEING DISMISSED: NOYES
DOES RUSSELL COUNTY PRESENTLY EMPLOY ANY RELATIVES OF YOURS BY BLOOD OR MARRIAGE: NOYES
DATE:
IF YOU ANSWERED “YES” TO ANY OF THE ABOVE THREE QUESTIONS, PLEASE EXPLAIN YOUR ANSWER IN THE SPACE PROVIDED BELOW:
ARE YOU PRESENTLY AN ELECTED OR APPOINTED OFFICIAL OR EMPLOYEE OF ANY STATE, COUNTY OR MUNICIPALITY:
STATE
NOYES FOR PURPOSES OF COMPLIANCE WITH §40.1-11.1 OF THE 1950 CODE OF VIRGINIA, PLEASE STATE WHETHER YOU ARE LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES:
Applicant Signature:
COUNTY OF RUSSELL, VIRGINIA WOARE Gr SunERvisore APPLICATION FOR EMPLOYMENT
‘ALL INFORMATION OBTAINED IN THIS APPLICATION WILL BE DISSEMINATED ONLY ACCORDING TO THE FEDERAL PRIVACY ACT OF 1076 FEDERAL LAW PROHIBITS DISCRIMINATION BECAUSE OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, OR HANDICAP. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, YOU MAY NOTIFY THE EQUAL EMPLOYMENT OPPORTUNITY COMMISSION. THE COUNTY OF| RUSSELL, VIRGINIA RESERVES THE RIGHT TO ACCEPT APPLICATIONS FOR EMPLOYMENT ONLY FOR SPECIFICALLY ADVERTISED POSITIONS. THE COUNTY DEPARTMENT OF HUMAN RESOURCES RETAINS ALL APPLICATIONS RECEIVED FOR ONE (1) YEAR.
APPLICANTS MAY SUBMIT RESUMES CONTAINING THE SAME INFORMATION IN LIEU OF PAGES 2 THROUGH 4 OF THIS APPLICATION. PLEASE| ‘COMPLETE AND ATTACH THIS PAGE AS COVER TO THE RESUME.
POSITION APPLIED FOR
POSITION TITLE OFFICE, DEPARTMENT, OR AGENCY
‘APPLICANT NAME,
FIRST, MIDDLE, AND LAST NAME
"APPLICANT CONTACT INFORMATION ‘APPLICANT MAILING ADDRESS:
STREET ADDRESS OR P.O. BOX cay STATE ZIPCODE AREACODE & HOME TELEPHONE
AREA CODE & WORKTELEPHONE AREACODE & MOBILE TELEPHONE E-MAIL
HOW LONG HAVE YOU LIVED AT THIS ADDRESS: MOSWR
‘APPLICANT GENERAL INFORMATION DO YOUHAVEAVALIDDRIVERSLICENSE: YES [] NO [] STATE OF ISSUE
‘COMMERCIAL DRIVERS LICENSE CLASS: LICENSE NO.
HAVE YOU BEEN EMPLOYED BY RUSSELLCOUNTY BEFORE! = YES. []NO [] IF YES, WHEN ANDINWHAT CAPACITY:
WHAT DATE WOULD YOU BE AVAILABLE TO BEGIN EMPLOYMENT: [ARE YOU PRESENTLY AN ELECTED OR APPOINTED OFFICIAL OR EMPLOYEE OF ANY STATE, COUNTY OR MUNICIPALITY: YES [] NO [)
HAVE YOU EVER BEEN DISMISSED FROM EMPLOYMENT OR FORCED TO RESIGN, OR RESIGNED IN ORDER TO AVOID BEING DISMISSED: YES [] NO []
DOES RUSSELL COUNTY PRESENTLY EMPLOY ANY RELATIVES OF YOURS BY BLOOD OR MARRIAGE: YES [] noo IF YOU ANSWERED “YES" TO ANY OF THE ABOVE THREE QUESTIONS, PLEASE EXPLAIN YOUR ANSWER IN THE SPACE PROVIDED BELOW:
FOR PURPOSES OF COMPLIANCE WITH §40.1-11.1 OF THE 1950 CODE OF VIRGINIA, PLEASE STATE WHETHER YOU ARE LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES: YES_[] NO []
‘APPLICANT CERTIFICATION & AUTHORIZATION TO RELEASE INFORMATION
|THE UNDERSIGNED HEREBY SUBMIT THIS APPLICATION FOR EMPLOYMENT FOR THE POSITION INDICATED HEREON, THE INFORMATION PROVIDED IN THIS APPLICATION FOR EMPLOYMENT AND SUPPORTING DOCUMENTATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. | UNDERSTAND THAT IF EMPLOYED, FALSE STATEMENTS ON THIS APPLICATION AND SUPPORTING. DOCUMENTATION SHALL BE CONSIDERED SUFFICIENT CAUSE FOR TERMINATION OF EMPLOYMENT.
| FURTHER HEREBY AUTHORIZE THE RUSSELL COUNTY BOARD OF SUPERVISORS TO INSPECT AND COPY ANY DOCUMENTS, RECORDS AND. INFORMATION RELATING TO MY CRIMINAL, TRAFFIC OR CREDIT RECORD. THIS AUTHORIZATION INCLUDES, BUT IS NOT LIMITED TO, AUTHORIZATION TO VERIFY INFORMATION SUBMITTED THROUGH PERSONAL INTERVIEW TO ASSIST IN THE BACKGROUND INVESTIGATION. | HEREBY RELEASE THE COUNTY OF RUSSELL VIRGINIA, ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY AND RESPONSIBILITY ARISING OUT OF THE OBTAINING OR RELEASE OF ANY INFORMATION CONCERNING ME IN CONNECTION WITH THIS BACKGROUND INVESTIGATION.
RUSSELL COUNTY PROMOTES A DRUG-FREE WORK ENVIRONMENT. IF A JOB OFFER IS EXTENDED TO YOU, YOU WILL BE REQUIRED TO SUBMIT TO AND PASS A DRUG AND/OR ALCOHOL TEST BEFORE BEGINNING WORK. ADDITIONALLY, A DRUG TEST MAY BE REQUIRED ON A, RANDOM BASIS AND FOLLOWING A WORK-RELATED ACCIDENT WITH INJURY OR PROPERTY DAMAGE.
IN CONSIDERATION OF EMPLOYMENT WITH THE COUNTY OF RUSSELL, VIRGINIA, | AGREE TO CONFORM TO THE POLICIES, RULES AND. REGULATIONS OF THE COUNTY, AND | UNDERSTAND AND AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF THE COUNTY OR MYSELF. | UNDERSTAND THAT NO OTHER EMPLOYEE HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING.
Applicant Signature: DATE:
APPLICATION FOR EMPLOYMENT PAGE 2
APPLICANT EDUCATION & MILITARY SERVICE
GRADUATE/COMPLETE:
NAME OF HIGH SCHOOL OR GED:
CITY: STATE:
YEARS ATTENDING: TO: NOYES
ACTIVE RESERVE DESIGNATION:
BRANCH OF ARMED SERVICES:
RANK AT DISCHARGE:YEARS IN SERVICE: TO: NOYES
GRADUATE/COMPLETE:
NAME OF VOCATION/BUSINESS SCHOOL:
CITY: STATE:
YEARS ATTENDING: TO: NOYES
M.O.S. AT DISCHARGE:
SPECIAL TRAINING/SCHOOLS:
DEGREE/CERTIFICATE EARNED:
MAJOR COURSE OF STUDY:
GRADUATE/COMPLETE:
NAME OF UNDERGRADUATE COLLEGE/UNIVERSITY:
CITY: STATE:
YEARS ATTENDING: TO: NOYES
DEGREE/CERTIFICATE EARNED:
MAJOR/MINOR:
GRADUATE/COMPLETE:
NAME OF POSTGRADUATE COLLEGE/UNIVERSITY:
CITY: STATE:
YEARS ATTENDING: TO: NOYES
DEGREE/CERTIFICATE EARNED:
MAJOR:
OTHER EDUCATIONTRAINING/CERTIFICATIONS RELEVANT TO THE POSITION YOU ARE APPLYING FOR, INCLUDING
FAMILARITY WITH COMPUTER SOFTWARE APPLICATIONS:AREA CODE & TELEPHONE NO.
APPLICANT REFERENCES
NAME OF REFERENCE
AREA CODE & TELEPHONE NO.NAME OF REFERENCE
AREA CODE & TELEPHONE NO.NAME OF REFERENCE
PLEASE LIST THREE PERSONS WHO ARE OF NO RELATION TO YOU WHO HAVE KNOWLEDGE OF YOUR QUALIFICATIONS OR CHARACTER – REFERENCES SHOULD BE PERSONS IN ADDITION TO PAST OR PRESENT EMPLOYER(S):
APPLICATION FOR EMPLOYMENT PAGE 2
‘APPLICANT EDUCA’
IN & MI
RY SERVICE
NAME OF HIGH SCHOOL OR GED:
cry: STATE: YEARS ATTENDING: T
GRADUATEICOMPLETE: yes 1 no O
BRANCH OF ARMED SERVICES:
YEARS IN SERVICE: TO: RANK AT DISCHARGE: ACTIVE RESERVE DESIGNATION: YES []_ NOC]
M.O.S. AT DISCHARGE:
‘SPECIAL TRAINING/SCHOOLS:
NAME OF VOCATION/BUSINESS SCHOOL:
cry: STATE:
YEARS ATTENDING: TO: GRADUATEICOMPLETE: YES [] NO DEGREEICERTIFICATE EARNED:
MAJOR COURSE OF STUDY:
NAME OF UNDERGRADUATE COLLEGE/UNIVERSITY: cry: STATE:
YEARS ATTENDING: TO: GRADUATEICOMPLETE: YES [] NO DEGREEICERTIFICATE EARNED:
MAJORIMINOR:
NAME OF POSTGRADUATE COLLEGE/UNIVERSITY: cry: STATE:
YEARS ATTENDING: TO: GRADUATEICOMPLETE: YES [] NO DEGREEICERTIFICATE EARNED:
MAJOR:
OTHER EDUCATIONTRAINING/CERTIFICATIONS RELEVANT TO THE POSITION YOU ARE APPLYING FOR, INCLUDING FAMILARITY WITH COMPUTER SOFTWARE APPLICATIONS:
‘APPLICANT REFERENCES.
PLEASE LIST THREE PERSONS WHO ARE OF NO RELATION TO YOU WHO HAVE KNOWLEDGE OF YOUR QUALIFICATIONS OR CHARACTER ~ REFERENCES SHOULD BE PERSONS IN ADDITION TO PAST OR PRESENT EMPLOYER(S),
NAME OF REFERENCE ‘REA CODE & TELEPHONE NO.
NAME OF REFERENCE ‘AREA CODE & TELEPHONE NO.
NAME OF REFERENCE ‘AREA CODE & TELEPHONE NO.
APPLICATION FOR EMPLOYMENT PAGE 3
APPLICANT EMPLOYMENT HISTORY
MAY WE CONTACT THIS EMPLOYER:
- NAME OF CURRENT OR MOST RECENT EMPLOYER: TIME EMPLOYED- FROM: TO:
NOYES
AREA CODE & TELEPHONEZIP CODESTATECITYSTREET ADDRESS OR P.O. BOX
CURRENT OR MOST RECENT EMPLOYER MAILING ADDRESS:
EMPLOYER WEBSITE
TYPE OF BUSINESS:
YOUR JOB/POSITION TITLE:
DESCRIPTION OF JOB/POSITION RESPONSIBILITIES:
NAME OF IMMEDIATE SUPEVISOR:
SUPERVISOR’S JOB/POSITION TITLE:
IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO
CONTACT:
NAME OF CONTACT PERSON & JOB TITLE AREA CODE & TELEPHONE
CONTACT PERSON E-MAIL
MAY WE CONTACT THIS EMPLOYER:
- NAME OF PAST EMPLOYER (EMPLOYER PRECEDING #1): TIME EMPLOYED- FROM: TO:
NOYES
AREA CODE & TELEPHONEZIP CODESTATECITYSTREET ADDRESS OR P.O. BOX
PAST EMPLOYER MAILING ADDRESS:
EMPLOYER WEBSITE
TYPE OF BUSINESS:
YOUR JOB/POSITION TITLE:
DESCRIPTION OF JOB/POSITION RESPONSIBILITIES:
NAME OF IMMEDIATE SUPEVISOR:
SUPERVISOR’S JOB/POSITION TITLE:
IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO
CONTACT:
NAME OF CONTACT PERSON & JOB TITLE AREA CODE & TELEPHONE
CONTACT PERSON E-MAIL
APPLICATION FOR EMPLOYMENT PAGE 3
1, NAME OF CURRENT OR MOST RECENT EMPLOYER:
TIME EMPLOYED- FROM: TO:
CURRENT OR MOST RECENT EMPLOYER MAILING ADDRESS:
‘STREETADDRESS ORP.O.BOX.——~—~—~=CSTTY, STATE ZIPCODE AREACODE & TELEPHONE
EMPLOYER WEBSITE TYPE OF BUSINESS:
YOUR JOB/POSITION TITLE:
DESCRIPTION OF JOB/POSITION RESPONSIBILITIES:
NAME OF IMMEDIATE SUPEVISOR:
‘SUPERVISOR’S JOB/POSITION TITLE:
MAY WE CONTACT THIS EMPLOYER: YES [] NO []_ IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO ‘CONTACT:
NAME OF CONTACT PERSON & JOB TITLE ‘REA CODE & TELEPHONE
CONTACT PERSON E-MAIL
- NAME OF PAST EMPLOYER (EMPLOYER PRECEDING #1) TIME EMPLOYED- FROM: TO:
PAST EMPLOYER MAILING ADDRESS:
‘STREETADDRESS ORP.O.6OX.——~—~=CSTTY, STATE ZIPCODE AREACODE & TELEPHONE
EMPLOYER WEBSITE TYPE OF BUSINESS:
YOUR JOB/POSITION TITLE:
DESCRIPTION OF JOB/POSITION RESPONSIBILITIES:
NAME OF IMMEDIATE SUPEVISOR:
‘SUPERVISOR’S JOB/POSITION TITLE:
MAY WE CONTACT THIS EMPLOYER: YES [] NO []_ IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO ‘CONTACT:
NAME OF CONTACT PERSON & JOB TITLE ‘REA CODE & TELEPHONE
CONTACT PERSON E-MAIL
APPLICATION FOR EMPLOYMENT PAGE 4
APPLICANT EMPLOYMENT HISTORY (CONTINUED)
MAY WE CONTACT THIS EMPLOYER:
- NAME OF PAST EMPLOYER (EMPLOYER PRECEDING #2): TIME EMPLOYED- FROM: TO:
NOYES
AREA CODE & TELEPHONEZIP CODESTATECITYSTREET ADDRESS OR P.O. BOX
PAST EMPLOYER MAILING ADDRESS:
EMPLOYER WEBSITE
TYPE OF BUSINESS:
YOUR JOB/POSITION TITLE:
DESCRIPTION OF JOB/POSITION RESPONSIBILITIES:
NAME OF IMMEDIATE SUPEVISOR:
SUPERVISOR’S JOB/POSITION TITLE:
IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO
CONTACT:
NAME OF CONTACT PERSON & JOB TITLE AREA CODE & TELEPHONE
CONTACT PERSON E-MAIL
MAY WE CONTACT THIS EMPLOYER:
- NAME OF PAST EMPLOYER (EMPLOYER PRECEDING #3): TIME EMPLOYED- FROM: TO:
NOYES
AREA CODE & TELEPHONEZIP CODESTATECITYSTREET ADDRESS OR P.O. BOX
PAST EMPLOYER MAILING ADDRESS:
EMPLOYER WEBSITE
TYPE OF BUSINESS:
YOUR JOB/POSITION TITLE:
DESCRIPTION OF JOB/POSITION RESPONSIBILITIES:
NAME OF IMMEDIATE SUPEVISOR:
SUPERVISOR’S JOB/POSITION TITLE:
IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO
CONTACT:
NAME OF CONTACT PERSON & JOB TITLE AREA CODE & TELEPHONE
CONTACT PERSON E-MAIL
APPLICATION FOR EMPLOYMENT PAGE 4
"APPLICANT EMPLOYMENT HISTORY (CONTINUED)
3, NAME OF PAST EMPLOYER (EMPLOYER PRECEDING #2):
TIME EMPLOYED- FROM: TO:
PAST EMPLOYER MAILING ADDRESS:
‘STREETADDRESS ORP.O.BOX.——~—~—~=CSTTY, STATE ZIPCODE AREACODE & TELEPHONE
EMPLOYER WEBSITE TYPE OF BUSINESS:
YOUR JOB/POSITION TITLE:
DESCRIPTION OF JOB/POSITION RESPONSIBILITIES:
NAME OF IMMEDIATE SUPEVISOR:
‘SUPERVISOR’S JOB/POSITION TITLE:
MAY WE CONTACT THIS EMPLOYER: YES [] NO []_ IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO ‘CONTACT:
NAME OF CONTACT PERSON & JOB TITLE ‘REA CODE & TELEPHONE
CONTACT PERSON E-MAIL
4, NAME OF PAST EMPLOYER (EMPLOYER PRECEDING #3) TIME EMPLOYED- FROM: TO:
PAST EMPLOYER MAILING ADDRESS:
‘STREETADDRESS ORP.O.6OX.——~—~=CSTTY, STATE ZIPCODE AREACODE & TELEPHONE
EMPLOYER WEBSITE TYPE OF BUSINESS:
YOUR JOB/POSITION TITLE:
DESCRIPTION OF JOB/POSITION RESPONSIBILITIES:
NAME OF IMMEDIATE SUPEVISOR:
‘SUPERVISOR’S JOB/POSITION TITLE:
MAY WE CONTACT THIS EMPLOYER: YES [] NO []_ IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO ‘CONTACT:
NAME OF CONTACT PERSON & JOB TITLE ‘REA CODE & TELEPHONE
CONTACT PERSON E-MAIL
COUNTY OF RUSSELL, VIRGINIA BOARD OF SUPERVISORS APPLICATION FOR EMPLOYMENT ALL INFORMATION OBTAINED IN THIS APPLICATION WILL BE DISSEMINATED ONLY ACCORDING TO THE FEDERAL PRIVACY ACT OF 1976. FEDERAL LAW PROHIBITS DISCRIMINATION BECAUSE OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, OR HANDICAP. IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, YOU MAY NOTIFY THE EQUAL EMPLOYMENT OPPORTUNITY COMMISSION. THE COUNTY OF RUSSELL, VIRGINIA RESERVES THE RIGHT TO ACCEPT APPLICATIONS FOR EMPLOYMENT ONLY FOR SPECIFICALLY ADVERTISED POSITIONS. THE COUNTY DEPARTMENT OF HUMAN RESOURCES RETAINS ALL APPLICATIONS RECEIVED FOR ONE (1) YEAR. APPLICANTS MAY SUBMIT RESUMES CONTAINING THE SAME INFORMATION IN LIEU OF PAGES 2 THROUGH 4 OF THIS APPLICATION. PLEASE COMPLETE AND ATTACH THIS PAGE AS COVER TO THE RESUME. POSITION APPLIED FOR APPLICANT NAME APPLICANT CONTACT INFORMATION APPLICANT MAILING ADDRESS: HOW LONG HAVE YOU LIVED AT THIS ADDRESS: I THE UNDERSIGNED HEREBY SUBMIT THIS APPLICATION FOR EMPLOYMENT FOR THE POSITION INDICATED HEREON. THE INFORMATION PROVIDED IN THIS APPLICATION FOR EMPLOYMENT AND SUPPORTING DOCUMENTATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT IF EMPLOYED, FALSE STATEMENTS ON THIS APPLICATION AND SUPPORTING DOCUMENTATION SHALL BE CONSIDERED SUFFICIENT CAUSE FOR TERMINATION OF EMPLOYMENT. I FURTHER HEREBY AUTHORIZE THE RUSSELL COUNTY BOARD OF SUPERVISORS TO INSPECT AND COPY ANY DOCUMENTS, RECORDS AND INFORMATION RELATING TO MY CRIMINAL, TRAFFIC OR CREDIT RECORD. THIS AUTHORIZATION INCLUDES, BUT IS NOT LIMITED TO, AUTHORIZATION TO VERIFY INFORMATION SUBMITTED THROUGH PERSONAL INTERVIEW TO ASSIST IN THE BACKGROUND INVESTIGATION. I HEREBY RELEASE THE COUNTY OF RUSSELL VIRGINIA, ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY AND RESPONSIBILITY ARISING OUT OF THE OBTAINING OR RELEASE OF ANY INFORMATION CONCERNING ME IN CONNECTION WITH THIS BACKGROUND INVESTIGATION. RUSSELL COUNTY PROMOTES A DRUG-FREE WORK ENVIRONMENT. IF A JOB OFFER IS EXTENDED TO YOU, YOU WILL BE REQUIRED TO SUBMIT TO AND PASS A DRUG AND/OR ALCOHOL TEST BEFORE BEGINNING WORK. ADDITIONALLY, A DRUG TEST MAY BE REQUIRED ON A RANDOM BASIS AND FOLLOWING A WORK-RELATED ACCIDENT WITH INJURY OR PROPERTY DAMAGE… IN CONSIDERATION OF EMPLOYMENT WITH THE COUNTY OF RUSSELL, VIRGINIA, I AGREE TO CONFORM TO THE POLICIES, RULES AND REGULATIONS OF THE COUNTY, AND I UNDERSTAND AND AGREE THAT MY EMPLOYMENT AND COMPENSATION CAN BE TERMINATED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF THE COUNTY OR MYSELF. I UNDERSTAND THAT NO OTHER EMPLOYEE HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING. APPLICANT CERTIFICATION & AUTHORIZATION TO RELEASE INFORMATION APPLICANT GENERAL INFORMATION DO YOU HAVE A VALID DRIVERS LICENSE: HAVE YOU BEEN EMPLOYED BY RUSSELL COUNTY BEFORE: IF YES, WHEN AND IN WHAT CAPACITY: HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OR CIVIL OFFENSE AGAINST THE LAW, INCLUDING MOVING TRAFFIC VIOLATIONS BUT EXCLUDING OFFENSES COMMITTED BEFORE YOUR 18TH BIRTHDAY HAVE YOU EVER BEEN DISMISSED FROM EMPLOYMENT OR FORCED TO RESIGN, OR RESIGNED IN ORDER TO AVOID BEING DISMISSED: DOES RUSSELL COUNTY PRESENTLY EMPLOY ANY RELATIVES OF YOURS BY BLOOD OR MARRIAGE: IF YOU ANSWERED “YES” TO ANY OF THE ABOVE THREE QUESTIONS, PLEASE EXPLAIN YOUR ANSWER IN THE SPACE PROVIDED BELOW: ARE YOU PRESENTLY AN ELECTED OR APPOINTED OFFICIAL OR EMPLOYEE OF ANY STATE, COUNTY OR MUNICIPALITY: FOR PURPOSES OF COMPLIANCE WITH §40.1-11.1 OF THE 1950 CODE OF VIRGINIA, PLEASE STATE WHETHER YOU ARE LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES: APPLICATION FOR EMPLOYMENT PAGE 2 APPLICANT EDUCATION & MILITARY SERVICE GRADUATE/COMPLETE: ACTIVE RESERVE DESIGNATION: GRADUATE/COMPLETE: GRADUATE/COMPLETE: GRADUATE/COMPLETE: OTHER EDUCATIONTRAINING/CERTIFICATIONS RELEVANT TO THE POSITION YOU ARE APPLYING FOR, INCLUDING FAMILARITY WITH COMPUTER SOFTWARE APPLICATIONS: APPLICANT REFERENCES PLEASE LIST THREE PERSONS WHO ARE OF NO RELATION TO YOU WHO HAVE KNOWLEDGE OF YOUR QUALIFICATIONS OR CHARACTER – REFERENCES SHOULD BE PERSONS IN ADDITION TO PAST OR PRESENT EMPLOYER(S): APPLICATION FOR EMPLOYMENT PAGE 3 APPLICANT EMPLOYMENT HISTORY MAY WE CONTACT THIS EMPLOYER: CURRENT OR MOST RECENT EMPLOYER MAILING ADDRESS: DESCRIPTION OF JOB/POSITION RESPONSIBILITIES: IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO CONTACT: MAY WE CONTACT THIS EMPLOYER: PAST EMPLOYER MAILING ADDRESS: DESCRIPTION OF JOB/POSITION RESPONSIBILITIES: IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO CONTACT: APPLICATION FOR EMPLOYMENT PAGE 4 APPLICANT EMPLOYMENT HISTORY (CONTINUED) MAY WE CONTACT THIS EMPLOYER: PAST EMPLOYER MAILING ADDRESS: DESCRIPTION OF JOB/POSITION RESPONSIBILITIES: IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO CONTACT: MAY WE CONTACT THIS EMPLOYER: PAST EMPLOYER MAILING ADDRESS: DESCRIPTION OF JOB/POSITION RESPONSIBILITIES: IF YES, PLEASE PROVIDE NAME & TELEPHONE NUMBER OF PERSON TO CONTACT: 8.2.1.4029.1.523496.503679 TextField1: TextField2: TextField3: CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 CheckBox1: 0 DateTimeField1: NumericField1: DateTimeField2: DropDownList1: TextField4: TextField5: