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Employmentapp Employment Application (CITY OF HOPEWELL)

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BROWSE CITY OF HOPEWELL (VA) FORMS

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Applicant’s Name:
APPLICATION FOR EMPLOYMENT
AN EQUAL OPPORTUNITY EMPLOYER
COMMITTED TO WORKPLACE DIVERSITY
Employees and applicants for employment shall be afforded equal opportunity in all aspects of
employment without regard to race, color, religion, national origin, gender, veteran status, age,
partisan political affiliation, or other non-merit or non-job-related factors, including any physical
disabilities which do not affect job performance.
We appreciate the opportunity to review your qualifications for employment with the City. So
that we can thoroughly consider your special skills and abilities, we would appreciate your
completion of our Employment Application. This employment application will only be valid for
one year from the date of the application. If you wish to be considered for employment
subsequent to that date, a new application must be completed. This completed application and
any materials submitted with it are the property of the City of Hopewell and will not be returned.
Thank you.
POSITION
Position applied for
Position No.
Department
Date available for work
Full-time Part-time Specify hours
Temporary Shift: Day Evening Night Rotating Weekend All shifts
(Please print legibly or type)
Last Name
First Name
M.I.
Social Security Number
-
-
Address
City
State
Zip
Phone
(
804
)
OTHER INFORMATION
Are you legally eligible to work in United States? Yes No
Have you previously worked with the City of Hopewell? Yes No
If yes, please list dates of employment
From
To
Do you have any relatives employed with the City of Hopewell? Yes No
Name:
Department:
Have you ever been convicted of a felony? Yes No
If yes, please explain and give dates:
Do you have a valid driver’s license? YES No
State of issuance:
Note: Applicants for positions entailing the use of City vehicles must provide a copy of their Driving Record from the Department of Motor Vehicles.
U.S. Military experience? Yes No
Branch:
How did you come to apply? Employee referral Former Employee Newspaper Ad Walk-in
Internet Website College Recruitment Other
EDUCATION
High School Attended
Did you Graduate?
Highest Grade Completed
Yes No
Location:
Did you have an equivalency diploma (GED)? Where Obtained?
Where Obtained?
Yes No
School Name and Address of School
Years
Completed
Did you
Graduate?
Type of
Diploma or Certificate
College
Yes No
Graduate school
Yes No
Other
Yes No
APPLICATION FOR EMPLOYMENT
AN EQUAL OPPORTUNITY EMPLOYER
COMMITTED TO WORKPLACE DIVERSITY
City of Hopewell
Human Resources
300 N. Main Street
Hopewell, VA 23860
Phone: (804) 541-2211
Or (804) 542-2245
www.hopewellva.gov
Mail Application to:
WORK EXPERIENCE
Starting with most recent, describe all paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities
which best demonstrate your qualifications for the position you are seeking. You may list significantly different jobs within the same
organization as separate items. Attach additional information if necessary,
but you must complete this entire application.
May we contact your current employer and/or coworkers? Yes No May we contact your former employers and/or coworkers? Yes No
Name & Address of Company
From To
Starting Salary
Per
Ending Salary
Per
Reason for leaving
Supervisor
Duties:
Position
Phone
Name & Address of Company
From To
Starting Salary
Per
Ending Salary
Per
Reason for leaving
Supervisor
Duties:
Position
Phone
Name & Address of Company
From To
Starting Salary
Per
Ending Salary
Per
Reason for leaving
Supervisor
Duties:
Position
Phone
Name & Address of Company
From To
Starting Salary
Per
Ending Salary
Per
Reason for leaving
Supervisor
Duties:
Position
Phone
Name & Address of Company
From To
Starting Salary
Per
Ending Salary
Per
Reason for leaving
Supervisor
Duties:
Position
Phone
PERSONAL REFERENCES
(Do not include relatives)
NAME
ADDRESS
TELEPHONE
(
)
-
( ) -
( ) -
NOTICE TO APPLICANTS AND EMPLOYEES
The City of Hopewell is an equal opportunity/affirmative action employer.
To this end, the City of Hopewell maintains affirmative action plans for
minorities and women, the disabled and veterans of the Vietnam era,
special disabled veterans and other covered veterans. These plans, or
portions thereof, that will enable you to avail yourself of their benefits, are
available for inspection by contacting the Human Resources Director
during normal business hours.
This employer wishes to comply with Section 503 of the Rehabilitation Act
of 1973, as amended, and it’s implementing regulations, which require it to
take affirmative action to employ and advance in employment qualified
disabled individuals. If you have such a disability and would like to be so
considered for purposes of this law, please identify yourself either
immediately or at any time in the future in confidence to the Human
Resources Director. Submission of this information is voluntary, and
refusal to provide it will not subject you to any adverse treatment. The
information provided will be kept confidential, and shall be maintained in a
separate file and will be used only in accordance with Federal regulations.
This employer wishes to comply with the Vietnam Era Veterans’
Readjustment Assistance Act of 1974, as amended, and it’s implementing
regulations requiring it to take affirmative action to employ and advance in
employment veterans of the Vietnam era, special disabled veterans and
other covered veterans. In this regard, if you believe you may be covered
by this law and wish to be treated accordingly, please identify yourself
either immediately or at any time in the future in confidence to the Human
Resources Director. Submission of this information is voluntary, and
refusal to provide it will not subject you to any adverse treatment. The
information provided will be kept confidential and will be used only in
accordance with Federal regulations.
DEFINITION OF THE TERM “INDIVIDUAL WITH A DISABILITY” FOR
PURPOSES OF VOLUNTARY SELF-IDENTIFICATION:
“Individual with a disability” means any person who:
(a) has a physical or mental impairment which substantially limits one of
more major life activities;
(b) has a record of such an impairment; or
(c) is regarded as having such an impairment; however, such term does
not include any individual who is currently engaging in the illegal use of
drugs, when the City acts on the basis of such use; any individual who
is an alcoholic whose current use of alcohol prevents such individual
from performing the essential functions of the employment position such
individual holds or desires or whose employment, by reason of such
current alcohol abuse, would constitute a direct threat to property or to
the health or safety of the individual or others; any individual who has a
currently contagious disease or infection and who, by reason of such
condition, would constitute a direct threat to the health or safety of the
individual or others or who, by reason of the currently contagious
disease or infection, is unable to perform the essential functions of the
employment position such individual holds or desires; any individual
who is homosexual or bisexual; or any individual on the basis of
transvestitism, transsexualism, pedophilia, exhibitionism, voyeurism,
gender identity disorders not resulting from physical impairment, other
sexual behavior disorders, compulsive gambling, kleptomania,
pyromania or psychoactive substance use disorders resulting from
current illegal use of drugs.
DEFINITION OF THE TERMS “VIETNAM ERA VETERAN”, “SPECIAL
DISABLED VETERAN” AND “OTHER COVERED VETERAN” FOR
PURPOSES
1. “Vietnam Era Veteran” means any person who: (a) served on active
duty for a period of more than 180 days, any part of which occurred
between August 5, 1964 and May 7, 1975, and was discharged or
released there from with other than a dishonorable discharge, or (b)
was discharged or released from active duty for a service-connected
disability if any part of such active duty was performed between August
5, 1964 and May 7, 1975. 2. “Special disabled veteran” means: (a) a
veteran who is entitled to compensation (or who but for the receipt of
military retired pay would be entitled to compensation) under laws
administered by the Veteran’s Administration for a disability rated at
thirty (30%) percent or more, or rated at ten (10%) percent or twenty
(20%) percent in the case of a veteran who has been determined under
38 U.S.C. § 3106 to have a serious employment handicap; or (b) a
veteran who was discharged or released from active duty because of a
service-connected disability.
3. “Other covered veteran” means: individuals who served on active duty
during a war or in a campaign or expedition for which a campaign
badge has been authorized. Active duty for training as a member of the
National Guard and Reserve does not qualify an individual for
Protection.
VOLUNTARY SELF-IDENTIFICATION FORM
The City of Hopewell
The City of Hopewell (the “City”) is an equal opportunity employer and
does not discriminate on the basis of race, color, sex, age, religion,
ancestry, national origin, sexual orientation, disability, or status as a
disabled, Vietnam Era or other covered veteran. As an equal opportunity
employer, the City complies with all relevant State and Federal
Government regulations and affirmative action responsibilities. Solely to
help us with record keeping, reporting, and other legal requirements, we
offer you the opportunity to complete this self-
identification form.
Submission of this information is completely voluntary. Whether you
provide this information or not, you will not be subject to adverse
treatment.
SEX
Male
Female
RACE
American Indian or Alaskan Native
Asian/Pacific Islander (includes Pakistanis and Indians)
Black or African American (includes Jamaican, Bahamians, and other
Caribbean persons of African but not Arabian or Hispanic decent)
White (includes Arabian)
Hispanic (includes persons of Mexican, Puerto Rican, Central or South
American or other Spanish origin or culture)
VETERANS
Special Disabled Veteran
Vietnam Era Veteran
Other Covered Veteran
PERSONS WITH DISABILITIES
Disabled
The provision of this information is on a voluntary basis and will be
maintained in a separate location for affirmative action program use and
will not be included in the personnel file of any employee.
POSITION(S) APPLIED FOR:
POSITION NO.
DATE:
SPECIALIZED SKILLS AND TRAINING Please indicate any skills acquired through training and/or experience.
Typing Speed
wpm Computer
Software Packages (list any you are proficient with):
Other Office Equipment :
Machinery :
State any additional information you feel may be helpful to us in considering your application:
READ CAREFULLY BEFORE SIGNING
Certificate of Application Information
I certify that the information I have provided to the previous questions is true and correct, and that no attempt has been made to
conceal pertinent information. I understand that if any information given by me in this application is found to be false or misleading,
I will be subject to dismissal at any time, and I agree to hold the City of Hopewell, its officials and employees harmless in that event.
Compliance With Immigration Law
I understand that federal law prohibits the employment of unauthorized aliens; all persons hired must submit satisfactory proof of
employment authorization and identity in accordance with applicable law; failure to submit such proof will result in denial of
employment.
Authorization to Obtain/Background Checks Information
I authorize the City of Hopewell to conduct a background investigation in connection with my application for employment. This
investigation may include information as to my credit, schools attended, police convictions, Division of Motor Vehicles records, present
employers, professional references, personal references, military records, and other appropriate sources.
Employment at Will
If employed by the City of Hopewell, I understand that my employment is for no definite period of time and I may be terminated at any
time, and that I, as an employee, may terminate my employment with the City of Hopewell at any time. I further understand that
employment with the City of Hopewell is not pursuant to any contract, either expressed or implied.
Drug Testing Information
I agree to submit to a physical examination, whenever requested in accordance with applicable law, and I understand my becoming
employed and/or my continued employment are subject to the results of any such physical examination related to my job duties in
accordance with City policies and procedures. In accordance with the Federal Drug Free Workplace Act, the City may require that
applicants for "Safety Sensitive" positions, positions requiring a Commercial Driver's License (CDL) and certain other full-time or
part-time positions complete a substance abuse test after an offer of employment has been made as a condition of employment.
ADA Notification
Under the American with Disabilities Act (ADA), I understand that I have the right to ask for reasonable accommodations at any stage of
the employment process. It is my responsibility to contact the Human R
esources Department, if reasonable accommodations are
needed.
Compliance with Work Policies, Rules and Instructions
In the event of my employment in a position with the City, I will comply with the all rules and regulations as set forth in its policy
documents, verbal and written instructions, and/or other communications distributed to employees. I understand that if employed, my
compliance with policies and rules which are issued is a condition of my continued employment and that the employer may revise
policies or procedures, in whole or in part, at any time.
Applicant’s Signature
Date
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Employmentapp Employment Application (CITY OF HOPEWELL)

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Completed 3 August 2020

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