Fillable APPLICATION FOR EMPLOYMENT (County of Campbell)

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APPLICATION FOR EMPLOYMENT (County of Campbell)

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U.S.A. forms for County of Campbell

BROWSE COUNTY OF CAMPBELL (VA) FORMS

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www.campbellcountyva.gov
CAMPBELL COUNTY SHERIFF’S OFFICE
Winston W. Clark III, Sheriff
P.O. Box 280 ● 87 Courthouse Lane ●
Rustburg, VA 24588
(434) 332-9580 ● (434) 332-
2710 fax
sheriff@campbellcountyva.gov
APPLICATION FOR EMPLOYMENT
Employees of the Commonwealth and applicants for appointment shall be afforded equal opportunity in all aspects of employment
without regard to race, color, religion, political affiliation, ethnicity, 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 contacting the Campbell County Sheriff’s Office.
APPLICANT INFORMATION
Full Legal
Name:
Date:
Last
First
M.I.
Address:
Street Address
City
State
Email
YES
NO
If no, are you authorized to work in the U.S.?
YES
NO
YES
NO
If yes, when?
Phone:
Social Security Number:
Position Applied for:
Are you a citizen of the United States?
Have you ever worked for Campbell County?
When are
you available to start work?
No date is necessary if you are available as soon as you complete a two (2) week notice.
EDUCATION
High School:
Address:
From:
To:
Did you graduate?
YES
NO
Diploma:
If you did not complete high school, do you have a general equivalency diploma (G.E.D.)?
YES
NO
College:
Address:
From:
To:
Did you graduate?
YES
NO
Degree:
Other:
Address:
From:
To:
Did you graduate?
YES
NO
Degree:
If you expect to complete an educational program in the future,
please indicate what type of program or
degree, and your
expected completion date.
Date:
Degree:
SUBMIT
SAVE
www.campbellcountyva.gov
PREVIOUS EMPLOYMENT
Please use an additional form(s) if necessary. Starting with the most recent, describe ALL paid, 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.
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Responsibilities
and duties
:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
YES
NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Responsibilities
and duties
:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
YES
NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Responsibilities
and duties
:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
YES
NO
www.campbellcountyva.gov
MILITARY SERVICE
Branch:
From:
To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
SKILLS AND ABILITIES
Use this space for any additional
information you think would help us
evaluate your application, including
training, seminars, workshops, or
achievements of
specialized skills.
Automated word
processing (specify
equipment)
Typing Speed
words per minute
Shorthand speed
words per minute
Licenses (to include driver’s), certificates or other authorizations to practice a trade or profession
Type
License Number
Granted By
REFERENCES
Please list three professional references.
Full Name:
Relationship:
Company:
Phone:
Address:
Email:
Full Name:
Relationship:
Company:
Phone:
Address:
Email:
Full Name:
Relationship:
Company:
Phone:
Address:
Email:
MISCELLANEOUS
Check which shift you will accept:
DAY
EVENING
NIGHT
ROTATING
WEEKENDS
Specify hours:
Check which shift you will accept:
PT
FT
Specify:
Check which employment status you will accept:
SALARIED
(with benefits)
HOURLY
(no benefits)
PT SALARIED
(leave benefits only)
Are you willing to accept employment
which requires you to travel? :
NO
YES
If yes,
DURING
DAY ONLY
OCCASSIONALLY
OVERNIGHT
FREQUENTLY
OVERNIGHT
www.campbellcountyva.gov
MISCELLANEOUS CONTINUED
List the geographic locations in which you are willing to work.
If all of Virginia, please write “all”.
Are you willing to provide your own transportation if necessary for employment?
NO
YES
For purposes of compliance with the Immigration Reform and Control Act of 1986, are you legally eligible for
employment in the United States?
Please note: you will be required to complete identity verification and
employment eligibility documentation upon employment.
NO
YES
Section 2.2-2804 of the Code of Virginia prohibits any board, commission, department agency, institution or
ins
trumentality 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?
NO YES
For purposes of compliance with Section 2.2
-2903 of the Code of Virginia, are you a veteran who received an
honorable discharge and has (a) provid
ed more than 180 consecutive days of full-time active-duty in the armed
forces of the United States or reserve components thereof, including the National Guard, or (
b) has a service-
connected disability rating fixed by the United States Veterans Affairs?
NO YES
If yes, did you serve during the Vietnam Conflict (2/28/1961 – 3/7/1975)?
NO
YES
Have you ever been convicted for any violation(s) of law, including moving traffic violations?
NO
YES
If yes, please provide the following:
Description of Offense
Statute or Ordinance (if known)
County, City, State of Conviction
Date of Charge(s)
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.
Date of Conviction
Disclaimer and 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 of any employment in the service of the Campbell
County Sheriff’s Office. I understand that all information on this application is subject to verification and I consent to criminal history
background checks. I also consent that you may contact references, former employers and educational institutions listed (to include
obtaining copies of school records) regarding this application. I further give consent to the Campbell County Sheriff’s Office to conduct
or request an employment investigation. This includes permission to investigate to secure my credit status and to obtain a copy of my
driving record for possible violation to the traffic laws. I further authorize the Campbell County Sheriff’s Office 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 or designee.
Signature:
Date:
CCSO RECEIVED DATE:
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APPLICATION FOR EMPLOYMENT (County of Campbell)

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Completed 17 July 2020

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