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?
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.
Section 2.2-2804 of the Code of Virginia prohibits any board, commission, department agency, institution or
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?
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?
If yes, did you serve during the Vietnam Conflict (2/28/1961 – 3/7/1975)?
Have you ever been convicted for any violation(s) of law, including moving traffic violations?
If yes, please provide the following:
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.
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.