Application for Employment (Louisa County)

Louisa County
SHERIFF’S OFFICE
P.O. Box 504
Louisa, Va. 23093

POSITION APPLIED FOR:*

x APPLICANT NAME:*

DATE OF APPLICATION:*

LOUISA COUNTY SHERIFF’S OFFICE
Donald A. Lowe, Sheriff
1 Woolfolk Avenue ● P.O.Box 504 ● Louisa, VA. 23093

APPLICATION FOR EMPLOYMENT

Position Applying For:*

Employment Type*

Full Time
Part Time

Personal Information:

First Name*

Middle Name

Last Name*

SS#

Height*

Weight*

Eyes*

Hair*

Address*

Street Address Address Line 2 City State ZIP Code

Telephone:

Home

Work

Pager

Cell

Please enter at least one phone number

Email Address:*

Maiden/Other Name(s) Used:

First Middle Last

Place of Birth:*

Attach a copy of your birth certificate to this application*

jpg, gif, png, pdf, doc, docx

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, 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*

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Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, 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

EDUCATION

High School

Name	Location	Field of Study	Diploma/Degree Received

Did you Graduate?*

Yes
No

College

Name	Location	Field of Study	Dates Attended	Diploma/Degree Received

Did you Graduate?*

Yes
No

Graduate School

Name	Location	Field of Study	Dates Attended	Diploma/Degree Received

Did you Graduate?*

Yes
No

Typing speed:*

WPM

List any computer software in which you are proficient:

List any interests, skills, honors, training, volunteer work, or other qualifications that may be helpful in considering your application :

EMPLOYMENT HISTORY
List current or most recent employer first

Name of Employer:

Immediate Supervisor:

Address

Street Address Address Line 2 City State ZIP Code

Phone

Dates of Employment:

From

To

Salary

Starting	Per	Ending

Job Description:

Reason for Leaving:

Employer may be contacted for reference

Yes
No

Add Another Employer?

Yes
No

Name of Employer:

Immediate Supervisor:

Address

Street Address Address Line 2 City State ZIP Code

Phone

Dates of Employment:

From

To

Salary

Starting	Per	Ending

Job Description:

Reason for Leaving:

Employer may be contacted for reference

Yes
No

Add Another Employer?

Yes
No

Name of Employer:

Immediate Supervisor:

Address

Street Address Address Line 2 City State ZIP Code

Phone

Dates of Employment:

From

To

Salary

Starting	Per	Ending

Job Description:

Reason for Leaving:

Employer may be contacted for reference

Yes
No

Add Another Employer?

Yes
No

Name of Employer:

Immediate Supervisor:

Address

Street Address Address Line 2 City State ZIP Code

Phone

Dates of Employment:

From

To

Salary

Starting	Per	Ending

Job Description:

Reason for Leaving:

Employer may be contacted for reference

Yes
No

Attach additional employment history if necessary

jpg, gif, png, pdf, doc, docx, xls

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, xls, Max. file size: 128 MB.

REFERENCES:*

Other than a supervisor listed in the employment section, who has knowledge of your qualifications
Tap "⊕" to add more

NAME	RELATIONSHIP	ADDRESS	TELEPHONE NUMBER

BACKGROUND INFORMATION/HISTORY
An answer of “yes” to any of these questions does not necessarily exclude you from consideration for employment. (Each incident will be judged on its own merit with respect to time, circumstances, and seriousness.)

Are you or any member of your family presently or formerly associated with any subversive organization?*

Yes
No

If yes, date

If yes, explain

Have you held an operator’s license in another state?*

Yes
No

If yes, date

If yes, explain

Have you been convicted of driving while your license was suspended or revoked?*

Yes
No

If yes, date

If yes, explain

Have you been convicted of any type of alcohol or drug related driving offense?*

Yes
No

If yes, date

If yes, explain

Have you been convicted of a felony or misdemeanor?*

Yes
No

If yes, date

If yes, explain

Have you ever been charged with a crime involving theft or moral turpitude (as an adult or juvenile)?*

Yes
No

If yes, date

If yes, explain

Have you been convicted of a moving traffic violation in the past 24 months?*

Yes
No

If yes, date

If yes, explain

Have you been dismissed or requested to resign from a former position?*

Yes
No

If yes, date

If yes, explain

Have 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, date

If yes, explain

Have you claimed bankruptcy, had wages garnished, or had a civil judgment against you?*

Yes
No

If yes, date

If yes, explain

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 information

PLEASE 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*

Date*

AUTHORIZATION TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

Applicant’s Name:*

Social Security #:*

This is to certify that I,*

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*

(year)*

Signature of Applicant*