APPLICATION FOR EMPLOYMENT

It is the policy of Carroll County to provide equal opportunity without regard to race, color, religion, sex age, national origin, marital status, disability, citizenship or veterans’ status.

As means of accommodation to persons with specific disabilities that prevent them from completing this application, confidential assistance in filling out this application may be obtained by calling the Human Resources Office.

APPLICANT INFORMATION

Position applying for? *

Last Name *

First Name *

Middle Name *

Address *

City *

State *

Zip Code *

Email Address

Area Code *

Phone *

Area Code

Alternate Phone

EDUCATION

High School 🛈

From:

To:

Last Year Completed.

	9	10	11	12
Years	9	10	11	12

Did you Graduate? (HS)

Yes

No

Type of Degree or Certification Received

College - Undergraduate 🛈

From:

To:

Last Year Completed.

	1	2	3	4
Years	1	2	3	4

Did you Graduate? (College)

Yes

No

Type of Degree or Certification Received

College - Graduate 🛈

From:

To:

Last Year Completed.

	1	2	3	4
Years	1	2	3	4

Did you Graduate? (Graduate)

Yes

No

Type of Degree or Certification Received

Other 🛈

From:

To:

Last Year Completed.

	1	2	3	4
Years	1	2	3	4

Did you Graduate? (Other)

Yes

No

Type of Degree or Certification Received

If you did not complete high school, do you have a high school equivalency diploma?

Yes

No

If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date. 🛈

Employment History

Starting with the most recent, describe ALL paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position. You may list significantly different jobs within the same organization as separate items. You may attach additional information but cannot substitute a resume for the application. You can download the Supplementary Experience Form here and upload below to attach this to your application if you need to add more than three (3).

To upload a copy of your resume.

To upload Supplementary Experience Form.

Employer 1

Position

Start

End

Company Name & Address (If Known)

Phone

STATUS

Full Time

Part Time

Reason for leaving:

Starting Salary:

Ending Salary:

Supervisor/Manager

Number and Titles of Employees You Supervised:

Duties:

Employer 2

Position

Start

End

Company Name & Address (If Known)

Phone

STATUS

Full Time

Part Time

Reason for leaving:

Starting Salary:

Ending Salary:

Supervisor/Manager

Number and Titles of Employees You Supervised:

Duties:

Employer 3

Position

Start

End

Company Name & Address (If Known)

Phone

STATUS

Full Time

Part Time

Reason for leaving:

Starting Salary:

Ending Salary:

Supervisor/Manager

Number and Titles of Employees You Supervised:

Duties:

If your name was different than present at any of the above-listed employers, please provide previous name(s) and at which employer(s) previous name(s) applied. 🛈

May we contact your present supervisor?

Yes

No

LICENSES, SPECIALIZED TRAINING AND OTHER SKILLS

List any license (to include driver's), certificate or other authorization to practice a skill or trade.

	Type	License Number	Expiration Date	Granted By (Licensing Board)
1.	Type	License Number	Expiration Date	Granted By (Licensing Board)
2.	Type	License Number	Expiration Date	Granted By (Licensing Board)
3.	Type	License Number	Expiration Date	Granted By (Licensing Board)

Use this space for any additional information you think would help us evaluate your application including : training, seminars, workshops, special achievements or specialized skills. Please include computer/software experience, trades and etc.

References

Reference 1

Name *

Address *

Phone *

Relationship *

Reference 2

Name *

Address *

Phone *

Relationship *

Reference 3

Name *

Address *

Phone *

Relationship *

ADDITIONAL APPLICANT INFORMATION

Have you ever been employed by Carroll County? If so, when and in what position? *

For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States? * 🛈

Yes

No

Section 2.2-2804 of the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality of the Commonwealth from employing a person who is required to present himself and submit to the federal Selective Service registration requirement and failed to do so. If you are/were required to register for the Selective Service, have you done so?

Yes

No

If NO, state reason.

For purposes of compliance with Section 2.2-2903 of the Code of Virginia, are you a veteran who received an honorable discharge and has (1) provided more that 180 consecutive days of full-time active-duty in the armed forces of the United States or reserve components thereof, including the National Guard, or (2) has a service-connected disability rating fixed by the United States Veterans Affairs? *

Yes

No

If YES, did you serve during the Vietnam Conflict (02/28/61 through 03/07/75)?

Yes

No

Check which shifts you will accept:

Check which job status you will accept:

Full-Time

Part-Time

Are you willing to accept employment which requires you to travel?

Yes

No

When will you be availible to start work?

Month

Day

Year

CERTIFICATION

I hereby certify that all entries on this application and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of the County of Carroll. I understand that all information on this application is subject to verification. I understand that drug screening may be required both pre-employment and during employment, and I consent to such drug screening. I also consent that you may contact references, former employers and educational institutions listed regarding this application. I further authorize Carroll County to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as determined by the agency head or designee.

Date: * +

Applicant Name: *