APPLICATION FOR
EMPLOYMENT
TOWN OF PURCELLVILLE
221 South Nursery Avenue, Purcellville, VA 20132
PHONE: (540) 338-7421 FAX: (540) 338-6205
Website: http://www.purcellvilleva.gov
AN EQUAL OPPORTUNITY EMPLOYER:
Under the provision of the Americans with Disability Act (ADA) reasonable accommodation will be made during
the selection process for this job upon your request. The Town of Purcellville considers all applicants without regard
to gender, race, religion, color, creed, age, disability, national origin, marital or veteran status, or any other legally
protected status.
Instructions: Please type or print in black ink. If more space is needed you may attach additional sheets with
your name and the position for which you are applying on the top of each page.
How did you learn about us?
□ Web page □ Friend or Relative
□ Newspaper Ad □ Employment Agency
□ Inquiry
□ Other _______________
a m. □
When is the best time to reach you at home? _____:_____p.m □
_____________________________________________________________________________________________
If you are under the age of 18, can you provide the required proof of your eligibility to work? □ Yes □ No
_____________________________________________________________________________________________
Have you ever filled out an application with the Town of Purcellville before? □ Yes □ No
If Yes, please give the date of your application ____________________________
_____________________________________________________________________________________________
Have you ever been employed with the Town of Purcellville before? □ Yes □ No
If Yes, please give the date of your employment ___________________________
_____________________________________________________________________________________________
Do any of your relatives, other than spouses or friends work for the Town of Purcellville? □ Yes □ No
If Yes, state name and relationship______________________________________
_____________________________________________________________________________________________
Are you currently employed? □Yes □ No
_____________________________________________________________________________________________
If Yes, may we contact your current employer? □ Yes □ No
_____________________________________________________________________________________________
Have you ever been fired or resigned from a position after being notified you were fired? □ Yes □ No
(If yes, explain) ___________________________________________________________
_____________________________________________________________________________________________
For the purpose of compliance with the United States Immigration and Nationalization Act, □ Yes □ No
and Section 40.1-11.1 of the Code of Virginia, are you legally eligible for employment in the
United States? Proof of Citizenship or immigration status will be required upon employment
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