Fillable Application for Employ m e n t (Virginia Judicial System)

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Application for Employ m e n t (Virginia Judicial System)

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Application for Employ m e n t
TO APPLICANT: We deeply appreciate your interest in our organization.Thank you for taking the time to complete this application.
The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law
also prohibits other types of discrimination such as age, citizenship, disability, veteran status, attainment of benefits, and participation
in union activities. The laws of most states and many localities also prohibit some or all of the above types of discrimination as well
as some additional types including, but not limited to, discrimination based upon ancestry, marital status, parental status, sexual
orientation, or source of income. The Fair Credit Reporting Act imposes restrictions with respect to information obtained from a
consumer reporting agency, including but not limited to information regarding credit data, personal character, general reputation and
mode of living. This list, however, is not exhaustive of the grounds on which discrimination is prohibited.
(PLEASE PRINT PLAINLY)
Date________________________________________
Name ____________________________________________________________________________________
Last First Middle
Social Security No.___________________________ Telephone No. __________________________________
Address __________________________________________________________________________________
No. Street City State Zip
Are you legally eligible for employment in the U.S.A.? Yes___ No___ If hired, you are required to submit
proof of your eligibility to work in the U.S.A.
Are you over the age of eighteen? Yes___ No___ If no, hire is subject to verification that you are of minimum
legal age.
Position(s) applied for________________________________________________________________________
Were you previously employed by us? Yes___ No___ If yes, when?__________________________________
If your application is considered favorably, on what date will you be available for work?
______________________
Are there any other job related experiences, skills, or qualifications which will be of special benefit in the job for
which you are applying?______________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(turn to next page)
© Copyright 1962, 1968, 1971, 1972, 1973, 1976, 1978, 1979, 1982, 1983, 1985, 1987, 1988, 1991, 1994, 1997, 1999—V.W. EIMICKE ASSOCIATES, INC., Bronxville, NY
Phone (914) 337-1900 • Fax (914) 337-1723 • E-mail vweimicke@eimicke.com • Website www.eimickehr.com FORM 101
PERSONAL
FOR OFFICE USE ONLY
Possible Work Locations Possible Positions
FOR OFFICE USE ONLY
Work
Location ____________
Position _____________
Rate________________
Date________________
List below present and past employment, beginning with your most recent
Name and Address of Company
From To
Weekly Weekly
Reason for Name of
and Type of Business
Mo. Yr. Mo. Yr.
Starting Last
Leaving Supervisor
Salary Salary
Describe the work you did:
Telephone
Name and Address of Company
From To
Weekly Weekly
Reason for Name of
and Type of Business
Mo. Yr. Mo. Yr.
Starting Last
Leaving Supervisor
Salary Salary
Describe the work you did:
Telephone
Name and Address of Company
From To
Weekly Weekly
Reason for Name of
and Type of Business
Mo. Yr. Mo. Yr.
Starting Last
Leaving Supervisor
Salary Salary
Describe the work you did:
Telephone
Name and Address of Company
From To
Weekly Weekly
Reason for Name of
and Type of Business
Mo. Yr. Mo. Yr.
Starting Last
Leaving Supervisor
Salary Salary
Describe the work you did:
Telephone
I
II
III
IV
I hereby give permission to contact the employers listed above concerning my prior work experience as indicated below.
Employer I? Yes______ No______
Employer II? Yes______ No______
Employer III? Yes______ No______
Employer IV? Yes______ No______
Signed ___________________________________________________________
—2—
EMPLOYMENT HISTORY
PERSONAL REFERENCES (Not Former Employers or Relatives)
—3—
Name and Occupation Address Phone Number
PLEASE READ AND SIGN BELOW
The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on
this application may result in my dismissal. I further understand that this application is not and is not intended to be a contract of
employment, nor does this application obligate the employer in any way if the employer decides to employ me. I understand and agree
that my employment is at-will and can be terminated by either party with or without notice, at any time, for any reason or no reason.
No one other than an officer of the Company has any authority to enter into any agreement for employment for any specified period of
time or to make any agreement contrary to the foregoing and then only in a writing signed by an officer.
Signature of Applicant
School Name and Address of School Course of Study
Circle Last
Did You
List
Year
Graduate?
Diploma
Completed or Degree
Elementary
High
College
Other
(Specify)
5 6 7 8
1 2 3 4
1 2 3 4
1 2 3 4
❏ Ye s
❏ No
❏ Ye s
❏ No
❏ Ye s
❏ No
❏ Ye s
❏ No
RECORD OF EDUCATION
May we telephone you to follow up on this application at home? Yes___ No___
If yes, what is the best time to call?_______________________________________________________________________________
May we telephone you to follow up on this application at work? Yes___ No___
If yes, what is the best time to call?_______________________________________________________________________________
What is your business telephone number?_____________________________________________
APPLICANT – Do not write on this page
FOR INTERVIEWER’S USE
FOR TEST ADMINISTRATOR’S USE
REFERENCE CHECK
INTERVIEWER DATE COMMENTS
TESTS
DATE
RAW
RATING COMMENTS AND INTERPRETATION
ADMINISTERED SCORE
*Position
RESULTS OF REFERENCE CHECK
*Position
RESULTS OF REFERENCE CHECK
Number Number
I
II
III
IV
*See Page 2
This “Application for Employment” is prepared for general use throughout the United States. Employment laws and legal requirements change
frequently, however. V.W. EIMICKE ASSOCIATES, INC. assumes no responsibility for an employer’s use of this form or any decision made in
connection with the form.
—4—
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Application for Employ m e n t (Virginia Judicial System)

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Completed 11 December 2021

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