Fillable APPLICATION FOR EMPLOYMENT TOWN OF PURCELLVILLE 221 South (Town of Purcellville)

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APPLICATION FOR EMPLOYMENT TOWN OF PURCELLVILLE 221 South (Town of Purcellville)

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  • 18 check-boxes
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File type: PDF

U.S.A. forms for Town of Purcellville

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APPLICATION FOR
EMPLOYMENT
TOWN OF PURCELLVILLE
221 South Nursery Avenue, Purcellville, VA 20132
PHONE: (540) 338-7421 FAX: (540) 338-6205
Website: http://www.purcellvilleva.gov
AN EQUAL OPPORTUNITY EMPLOYER:
Under the provision of the Americans with Disability Act (ADA) reasonable accommodation will be made during
the selection process for this job upon your request. The Town of Purcellville considers all applicants without regard
to gender, race, religion, color, creed, age, disability, national origin, marital or veteran status, or any other legally
protected status.
Instructions: Please type or print in black ink. If more space is needed you may attach additional sheets with
your name and the position for which you are applying on the top of each page.
Position(s) applied for:
Date of Application:
How did you learn about us?
□ Web page □ Friend or Relative
□ Newspaper Ad □ Employment Agency
□ Inquiry
□ Other _______________
Last Name First Name
Middle Name
Address: Number Street
City State Zip Code
Telephone Number
a m. □
When is the best time to reach you at home? _____:_____p.m □
_____________________________________________________________________________________________
If you are under the age of 18, can you provide the required proof of your eligibility to work? □ Yes □ No
_____________________________________________________________________________________________
Have you ever filled out an application with the Town of Purcellville before? □ Yes □ No
If Yes, please give the date of your application ____________________________
_____________________________________________________________________________________________
Have you ever been employed with the Town of Purcellville before? □ Yes □ No
If Yes, please give the date of your employment ___________________________
_____________________________________________________________________________________________
Do any of your relatives, other than spouses or friends work for the Town of Purcellville? □ Yes □ No
If Yes, state name and relationship______________________________________
_____________________________________________________________________________________________
Are you currently employed? □Yes □ No
_____________________________________________________________________________________________
If Yes, may we contact your current employer? □ Yes □ No
_____________________________________________________________________________________________
Have you ever been fired or resigned from a position after being notified you were fired? □ Yes □ No
(If yes, explain) ___________________________________________________________
_____________________________________________________________________________________________
For the purpose of compliance with the United States Immigration and Nationalization Act, □ Yes □ No
and Section 40.1-11.1 of the Code of Virginia, are you legally eligible for employment in the
United States? Proof of Citizenship or immigration status will be required upon employment
_____________________________________________________________________________________________
Applicant Name:_________________________________________
_____________________________________________________________________________________________
Date you are available for work ______/_____/______ What is your desired salary range? __________________
Are you available : Do you have a valid drivers license? □ Yes □ No
□ Full Time Please list the Name/State/Expiration Date ________
□ Part Time ___________________________________________
Can you travel if the job requires it? □ Yes □ No
_____________________________________________________________________________________________
Are you currently on “lay off” status and subject to recall? □ Yes □ No
EDUCATION
School
Name and Location
of School
Dates of
Enrollment
Degree or # of
Credits Completed
Major Area of
Study
High School or
Highest Grade
Completed
College or University
Graduate or
Professional School
Business or Trade
School
Other (Specify)
If you expect to complete an educational program in the near future, please indicate what type of degree you are
pursuing and when you expect to receive it:__________________________________________________________
WORK EXPERIENCE
List below present and past employment, beginning with the most recent. Include any related military service or
volunteer work. If appropriate, list number and title of employees you supervised in each position. You may attach a
resume as supplemental information, you may also use additional sheets, as necessary. Please put your name and the
title of the position for which you are applying on each sheet.
Name & Address of Employer
From
Mo./Yr.
To
Mo./Yr.
Starting
Salary
Ending
Salary
# of Hours
per Week
Reason for Leaving
Position
Title:
Supervisor’s Name//Phone
Description
of work:
Name & Address of Employer
From
Mo./Yr.
To Mo./Yr.
Starting
Salary
Ending
Salary
# of Hours
per Week
Reason for Leaving
Position
Title:
Supervisor’s Name/Phone
Description
of work:
Name & Address of Employer
From
Mo./Yr.
To Mo./Yr.
Starting
Salary
Ending
Salary
# of Hours
per Week
Reason for Leaving
Position
Title:
Supervisor’s Name/Phone
Description
of work:
Please explain any gaps in
employment
Awards or Certifications
Languages:
Specialized training, apprenticeship and/or skills and abilities received in the United States Military or elsewhere
Professional, trade, business or civic activities and offices held
You may exclude membership that would reveal gender, race, religion, national origin, age, ancestry,
or other protected status
Special Skills and Abilities
Computer Skills Office Skills
□ Mac/PC □ Type writer (WPM______)
□ Spreadsheet □ Short Hand
□ Word Processing □ Dictation
□ Databases □ Other_________________
Production/ Mobile Machinery
(list)
Other (List)
Additional information you feel may be helpful to us in considering your application
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
PERSONAL OR PROFESSIONAL REFERENCES (Please do not include family members or past supervisors)
Name Telephone Number Best Time to Call Relationship
1.
2.
3.
1. I certify that the statements in this application are true and complete to the best of my knowledge, and I
agree that any intentional misstatement or omission will constitute ground for unfavorable
consideration of my application or dismissal from employment with the Town of Purcellville
2. I authorize the Town of Purcellville to obtain information from past employers and other sources to
support the data on this application, including a review of my educational, criminal and credit records,
as appropriate
3.
This employment application shall be considered active for a period to time not to exceed 45 days.
Applicants wishing to be considered for employment beyond this time period should inquire as to
whether or not applications are being accepted at that time.
4. I understand and acknowledge that, unless otherwise defined by applicable law, any employment
relationship with the town of Purcellville is of an “at will” nature, which means that the Employee may
resign at any time and the Employer may discharge the Employee at any time with or without cause. I
further understand that this “at will” relationship with my employer may not be changed by any written
document or by conduct unless an authorized executive of the Town of Purcellville specifically
acknowledges such a change in writing.
5. I understand that I am required to abide by all rules and regulations of the employer.
Applicants Signature____________________________________________ Date_________________
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APPLICATION FOR EMPLOYMENT TOWN OF PURCELLVILLE 221 South (Town of Purcellville)

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Completed 14 July 2020

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