Application for Employment [Louisa County] Position Applied For*Applicant Name*Date of Application*Position Applying For*Shift Preference* Full Time Part Time Personal InformationLast Name*First Name*Middle Name*SS#*Weight*Height*Eyes*Hair*Street*City*State*Zip*Home Telephone #*Work Phone #*PagerCell #*Email Address*Maiden/Other Name(s) Used (LAST)*Maiden/Other Name(s) Used (FIRST)*Maiden/Other Name(s) Used (Middle)*Place of Birth*Attach a copy of your birth certificate to this application* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB. Are you a U.S. Citizen?* Yes No If Naturalized Citizen, Naturalization #When are you available to begin work?*What is the minimum salary you will accept?*Do you have a high school diploma or GED?* Yes No If yes, attach a COPY to this application Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB. Do you have a valid Virginia Operator’s License?* Yes No Are you willing to do or accept the following?Work shift work or rotating work?* Yes No Work weekends?* Yes No Work as a salaried employee with benefits?* Yes No Work as an hourly employee (no benefits)?* Yes No Part time employment?* Yes No Full time employment?* Yes No Travel if required to do so?* Yes No Provide your own transportation to work?* Yes No EducationHigh SchoolName*Location*Field of Study*Did you graduate?* Yes No Diploma/Degree Received*CollegeNameLocationField of StudyDates AttendedDid you graduate? Yes No Diploma/Degree ReceivedGrad SchoolSchool NameSchool LocationField of StudyDates AttendedDid you graduate? Yes No Diploma/Degree ReceivedLICENSE and CERTIFICATIONSDriver’s LicenseType*State*Number*Date Issued*Expiration*Do you want to add another License or Certificate?* Yes No License / Certificate 2License/Certificate NameLicense/Certificate TypeLicense/Certificate StateLicense/Certificate NumberLicense/Certificate Date IssuedLicense/Certificate ExpirationDo you want to add another License or Certificate? Yes No License / Certificate 3License/Certificate NameLicense/Certificate TypeLicense/Certificate StateLicense/Certificate NumberLicense/Certificate Date IssuedLicense/Certificate ExpirationDo you want to add another License or Certificate? Yes No License / Certificate 4License/Certificate NameLicense/Certificate TypeLicense/Certificate StateLicense/Certificate NumberLicense/Certificate Date IssuedLicense/Certificate ExpirationDo you want to add another License or Certificate? Yes No License / Certificate 5License/Certificate NameLicense/Certificate TypeLicense/Certificate StateLicense/Certificate NumberLicense/Certificate Date IssuedLicense/Certificate ExpirationTyping Speed*wpmList any computer software in which you are proficientList any interests, skills, honors, training, volunteer work, of other qualifications that may be helpful in considering your applicationEMPLOYMENT HISTORYList current or most recent employer firstApplicant Name*Name of Employer*Immediate Supervisor*Employer Street Address*Employer City*Employer State*Dates of Employment*Employer Telephone*Job Title*From*To*Salary Starting*Per*Salary Ending*Job Description*Reason for Leaving*Employer may be contacted for reference* Yes No Add another employer?* Yes No Employment HistoryName of EmployerImmediate SupervisorEmployer Street AddressEmployer CityEmployer StateDates of EmploymentEmployer TelephoneJob TitleFromToSalary StartingPerEndingJob DescriptionReason for LeavingEmployer may be contacted for reference Yes No Add another employer? Yes No Employment History 3Name of EmployerImmediate SupervisorEmployer Street AddressEmployer CityEmployer StateDates of EmploymentEmployer TelephoneJob TitleFromToStartingPerEndingJob DescriptionReason for LeavingEmployer may be contacted for reference Yes No Add another employer? Yes No Employment History 4Name of EmployerImmediate SupervisorEmployer Street AddressEmployer StateEmployer CityDates of EmploymentEmployer TelephoneJob TitleFromToStartingPerEndingJob DescriptionReason for LeavingEmployer may be contacted for reference Yes No If you have more employment history, you may attach it here. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, txt, odt, xls, xlsx, Max. file size: 128 MB. Job Related DocumentsOther Job Related Documents Drop files here or Select files Max. file size: 128 MB. REFERENCES(Other than a supervisor listed in the employment section, who has knowledge of your qualifications)Reference Name*Reference Relationship*Reference Address*Reference Telephone Number*Add another reference?* Yes No Reference 2Reference NameReference RelationshipReference AddressReference Telephone NumberAdd another reference? Yes No Reference 3Reference NameReference RelationshipReference AddressReference Telephone NumberAdd another reference? Yes No Reference 4Reference NameReference RelationshipReference AddressReference Telephone NumberBACKGROUND INFORMATION / HISTORYAre you or any member of your family presently or formerly associated with any subversive organization?* Yes No If Yes, DateIf Yes ExplainHave you held an operator’s license in another state?* Yes No If Yes, DateIf Yes ExplainHave you been convicted of driving while your license was suspended or revoked?* Yes No If Yes, DateIf Yes ExplainHave you been convicted of any type of alcohol or drug related driving offense?* Yes No If Yes, DateIf Yes ExplainHave you been convicted of a felony or misdemeanor?* Yes No If Yes, DateIf Yes ExplainHave you ever been charged with a crime involving theft or moral turpitude (as an adult or juvenile)?* Yes No If Yes, DateIf Yes ExplainHave you been convicted of a moving traffic violation in the past 24 months?* Yes No If Yes, DateIf Yes ExplainHave you been dismissed or requested to resign from a former position?* Yes No If Yes, DateIf Yes ExplainHave you, as a juvenile or adult, experimented or used any type of illegal substances or drugs including marijuana, cocaine, hallucinogens, etc?* Yes No If Yes, DateIf Yes ExplainHave you claimed bankruptcy, had wages garnished, or had a civil judgment against you?* Yes No If Yes, DateIf Yes Explain* An answer of “yes” to any of these questions does not necessarily exclude you from consideration for employment. (Each incident will be judged on it’s own merit with respect to time, circumstances, and seriousness.) Use additional sheets as necessary, and attach them below:. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, txt, odt, xls, xlsx, Max. file size: 128 MB. THE FOLLOWING ITEMS ARE REQUIRED TO BE SUBMITTED WITH THIS APPLICATION: 1-Copy of Birth Certificate 2-Copy of High School Diploma or GED 3-Authorization for release of informationPLEASE READ CAREFULLY AND SIGN BELOW; I certify that the answers and information given herein are true and complete. I hereby grant Louisa County Sheriff’s Office permission to request any school of learning, creditor, past or current employer or law enforcement agency to release information contained in their records for use in conducting research specifically relating to my suitability as an employee of Louisa County Sheriff’s Office, except where my written statement upon this form specifically requests that no investigation be made. I understand this information is for use by Louisa County Sheriff’s Office, and will be safeguarded against unauthorized disclosure to any agency or individual not having a legitimate need for it and the authority for its release. I understand any misrepresentation of facts in this application will be considered just cause for dismissal at the discretion of the Louisa County Sheriff’s Office. In the event that I am employed, I understand I am required to abide by the policies and procedures of the Louisa County Sheriff’s Office.Signature of Applicant*Applicant Signature Date*Witness Name*Witness Signature*Witness Signature Date*AUTHORIZATION TO RELEASE INFORMATIONTO WHOM IT MAY CONCERN:Applicant Name*Social Security #*This is to certify that I, [Applicant Name]*am an applicant for the position of*with the Louisa County Sheriff’s Office. I hereby authorize the release of any and all information to any employee or agent of the Louisa County Sheriff’s Office they may request, from whomever they may deem it necessary to make such request, from any of my records or files. Such information will include, but not be limited to, hospital records, military records, police records, arrest records, court records, police reports (including juvenile records), police polygraph examination reports, credit records and reports, background investigative material and reports, employment records, attendance records, traffic records, confidential records, educational records and transcripts, etc. I hereby release all persons from any and all liability that could result from furnishing this information to the Louisa County Sheriff’s Office. Further, I authorize the Louisa County Sheriff’s Office to copy or otherwise reproduce this original document, and to let such copied or otherwise reproduced copy act with the same authority as the original instrument. This original document is to be retained on file with the Louisa County Sheriff’s Office. I further understand neither the sources nor the confidential information provided will not be revealed or released to me, regardless of the status of my application.This authorization is given this*day of*20XX*Enter Last 2 Digits of Current YearSignature of Applicant*Witness Name*Witness Signature*This field is hidden when viewing the formFOR TESTING PURPOSESIf you would like to email a copy of the pdf to yourself, please enter your email address below.
