Fillable Altavista Job Application - Job Application

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Altavista Job Application - Job Application

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Country of origin: US
File type: PDF

U.S.A. forms for Town of Altavista

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POSITION FOR WHICH
YOU ARE APPLYING:
Last Name
First Name
Middle Initial
Mailing Address
City State Zip Home Telephone No.
Business Telephone No.
E-Mail Address
EDUCATION
HIGH SCHOOL
NAME & LOCATION OF SCHOOL:
RECEIVED: Diploma Other (specify) ______________________ None
Please circle the highest education level you have completed: 8
th
9
th
10
th
11
th
12
th
COLLEGE, UNIVERSITY OR PROFESSIONAL SCHOOL
NAME OF SCHOOL
LOCATION
DATES OF ATTENDANCE
FROM TO
MAJOR/MINOR
COURSE OF
STUDY
TYPE OF
DEGREE
EARNED
JOB-RELATED TRAINING OR COURSE WORK: (VOCATIONAL, TRADE, GOVERNMENTAL, BUSINESS, ARMED FORCES, ETC.
NAME OF SCHOOL
LOCATION
DATES OF ATTENDANCE
FROM TO
COURSE OF
STUDY
TRAINING
COMPLETED
YES NO
Licensure, Registration, Certification Examples: Inspector Certification; Plant Operator Certification; Code Compliance Certification, etc.
LICENSE, REGISTRATION OR CERTIFICATION: Number Date Received Expiration Date State Licensing Agency
TOWN OF ALTAVISTA
Application for Employment
510 7
th
Street / P. O. Box 420
Altavista, VA 24517
Phone (434) 369-5001 / Fax (434) 369-4369
Web Address: http://www.AltavistaVA.gov
EEO/ADA Employer
EMPLOYMENT
May we contact your present employer: Yes No
1
Starting Date
month / day / year
Ending Date
month / day / year
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone No.
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job responsibilities in order of importance:
2
Starting Date
month / day / year
Ending Date
month / day / year
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone No.
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job responsibilities in order of importance:
3
Starting Date
month / day / year
Ending Date
month / day / year
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone No.
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job responsibilities in order of importance:
4
Starting Date
month / day / year
Ending Date
month / day / year
Employer/Company Name and address (city and state are required)
Name & Title of Immediate Supervisor
Telephone No.
Reason for Leaving
Title of Position Held
Number & Job Title of Employees you Supervised
Describe job responsibilities in order of importance:
DRIVER’S LICENSE INFORMATION
Driver’s License # State Expiration Date
Operators (Private Vehicle)
CDL (copy needed of license & medical card)
BACKGROUND INFORMATION
A record of conviction (s) will not necessarily disqualify you from employment. Each situation is considered individually.
Withholding or
falsifying information may result in: Exclusion from further consideration/or, if hired immediate discharge.
IF HIRED, ARE YOU AUTHORIZED TO WORK IN THE UNITED STATES? YES NO
HAVE YOU EVER BEEN CONVICTED OF A FELONY OR FIRST DEGREE MISDEMEANOR? YES NO
If “YES,” what charges? _________________________________________________________________________________
Where convicted? _____________________________________ Date of Conviction__________________________________
HAVE YOU EVER PLED GUILTY TO A CRIME, WHICH IS A FELONY OR A FIRST DEGREE MISDEMEANOR? YES NO
If “YES,” what charges? ________________________________ Date ____________________________________________
Where? ______________________________________________________________________________________________
HAVE YOU EVER HAD THE ADJUDICATION OF GUILT WITHHELD TO A CRIME WHICH IS A FELONY OR A FIRST DEGREE MISDEMEANOR
YES NO
If “YES,” what charges? _________________________________________________________________________________
Where? ____________________________________________ Date _____________________________________________
REFERENCES
Name Telephone Number
SIGNATURE AUTHORIZATION
Your signature is required in order for your application to be considered. Please read the following information carefully
before signing.
Withholding or falsifying information may result in: Exclusion from further consideration: or, if hired
immediate discharge
.
By my signature below, the Town of Altavista has my authorization to thoroughly investigate my work, criminal and personal history that
are job-related. I authorize the Town of Altavista to obtain educational proof, including college or university transcripts as well as licensure
and employment references from my current and former employers. I will hold no individual, corporation or organization liable for giving
or receiving information during this investigation. I understand that if I am applying for a position that required the operation of a motor
vehicle, a driving record check will be conducted through the Department of Motor Vehicles. I also agree to submit to a medical
examination and/or drug/alcohol test, as required.
Additionally, I understand that falsifying, lying or omitting information on
this document will disqualify me for consideration for employment with the Town of Altavista or dismissal if currently
employed.
I certify that all statements made in this application are true, complete and correct to the best of my knowledge and belief
and are made in good faith.
__________________________________________________ ___________________________________________
APPLICANT SIGNATURE APPLICATION DATE
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Altavista Job Application - Job Application

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Completed 10 July 2020

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