Virginia Job Application – Fill Out and Use This PDF

d.Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, and special achievements or specialized skills:

e.Automated word processing (specify equipment)

11.REFERENCES

List names, addresses and relationships of three persons not related to you who know your qualifications:

12.MISCELLANEOUS

h.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:

i.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 (i) provided more than 180 consecutive days of full-time active- duty in the armed forces of the United States or reserve components thereof, including the National the National Guard, or (ii) has a service-connected disability rating fixed by the United States Veterans Affairs?

Yes No. If yes, did you serve during the Vietnam Conflict (2/28/61-3/7/75)? Yes No

j.Have you ever been convicted* for any violation(s) of law, including moving traffic violations. Yes No If YES, please provide the following:

Description of offense:

Statute or ordinance (if known ): Date of Charge: ; Date of Conviction

County, City, State of Conviction:

(For additional convictions use plain paper. Include all information listed above.)

*Convictions include Virginia juvenile adjudications for Capital Murder, First and Second Degree Murder, Lynching, or Aggravated Malicious Wounding, if you were age fourteen (14) to eighteen (18) when charged.

13.When will you be available to start work? (No date is necessary if you are available as soon as you give two (2) weeks notice.)

Month Day Year

14.CERTIFICATION--Each Application Requires Current Date and Original Signature

I hereby certify that all entries on both sides 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 Commonwealth of Virginia. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent that you may contact references, former employers and educational institutions listed regarding this application. I further authorize the Commonwealth 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.

Pursuant to federal regulations, we collect responses to the questions below for record keeping purposes. This information will NOT be kept with your application for employment. Federal law prohibits unlawful discrimination on the basis of race, color, sex, age, national origin, religion, or disability.

*specify name of newspaper or other media