Commonwealth of Virginia Department of Social Services

EMPLOYMENT APPLICATION

DATE:

If you need help in completing this application, please request assistance. (e.g., use initials of Health Care Organization) refers to (Name of Health Care Organization). (HCO) complies with all applicable laws concerning hiring and employment practices and is firmly committed to maintaining a workplace free from unlawful discrimination.

PLEASE PRINT LEGIBLY IN INK - In addition to completing this application, please submit your resume’ on-line at (website of HCO).

PERSONAL INFORMATION

Please write your name below as it appears on your social security card:

Social Security Number:

Present Address (City/Town State Zip Code):

Permanent Address (If Different):

Home Telephone Number: Work Telephone Number:

Cell Phone Number: E-mail Address:

Position for Which You are Applying:

Availability: Full Time Part Time Temporary Internship Evenings Weekends Other

Work Location Preference(s):

Are you currently authorized to work in the United States: yes no

Do you now, or will you in the future, require sponsorship for a work visa? yes no

Are you over 18 years of age? yes no If no, when will you turn 18?

Have you ever been employed by ? yes no

If you have been previously employed by , please specify the following:

From to Department Position

Location Supervisor

Names of any relatives employed by (HCO):

Name: Department Relationship

Name: Department Relationship

How did you hear about employment opportunities with (HCO)?

Employment Agency Job Fair HCO Website Advertisement Employee Referral Direct Recruitment Other

PRIOR WORK, MILITARY AND VOLUNTEER EXPERIENCE

In order that we may verify prior experience, have you used another name in your previous jobs?

No Yes give name and specify organization(s)

List most recent experience first. Please include volunteer experience.

1.

Name of Organization

Street Address, City, State, Zip Code

Title or Position Name of Supervisor

Duties Annual Salary or Hourly Rate

Dates Employed, From until Reason for Leaving

Can we contact Organization for reference? Yes No

2.

Name of Organization

Street Address, City, State, Zip Code

Title or Position Name of Supervisor

Duties Annual Salary or Hourly Rate

Dates Employed, From until Reason for Leaving

Can we contact Organization for reference? Yes No

3.

Name of Organization

Street Address, City, State, Zip Code

Title or Position Name of Supervisor

Duties Annual Salary or Hourly Rate

Dates Employed, From until Reason for Leaving

Can we contact Organization for reference? Yes No

REFERENCES

In addition to current and form employers, please list two additional professional references below that we may contact:

Name Relationship How long know,?

Company Title Daytime Phone No.

Evening Phone No. E-mail

Address (Street Address, City, State, Zip Code)

Name Relationship How long know,?

Company Title Daytime Phone No.

Evening Phone No. E-mail

Address (Street Address, City, State, Zip Code)

EDUCATION

Name of High School Graduate Yes No

Address (Street Address, City, State, Zip Code)

Name of College Graduate Yes No

Address (Street Address, City, State, Zip Code)

Type of Degree Year Major Minor

Other -- Name of School Graduated Yes No

Address (Street Address, City, State, Zip Code)

Type of Degree or Certificate Year Major

PROFESSIONAL LICENSES, REGISTRATIONS, AND CERTIFICATES

Type of License or Certificate Reg. No. Expiration Date State

Type of License or Certificate Reg. No. Expiration Date State

Type of License or Certificate Reg. No. Expiration Date State

Describe your working knowledge of computer software

CRIMINAL RECORD

Please complete this section on prior convictions. An applicant for employment with a sealed record on file with a court (such as a juvenile record) may answer “no record” with respect to an inquiry relative to prior arrests, criminal court appearances or convictions. A criminal arrest or conviction will not necessarily be a bar to employment.

1. Have you been convicted of a misdemeanor (excluding a first conviction for speeding or minor traffic violations) within the last five years? Yes No

2. Have you ever been convicted of a felony? Yes No

If you have answered yes to either of the above questions, please provide an explanation below.

PLEASE READ BEFORE SIGNING

I certify that all answers and statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, might affect this application unfavorably. I understand that any falsification, misrepresentation or material omission of information submitted on this application will constitute grounds for denial or immediate dismissal from employment.

I authorize all persons, schools, employers and other organizations mentioned in this application to provide (HCO) with any and all information requested by (HCO) related to my qualifications for employment.

I further understand that any job offer will be contingent upon satisfactory replies to background and reference checks and that information about the content and scope of such checks will be furnished to me if I make a written request for such information within a reasonable time.

I further understand that employment with (HCO) may be conditioned upon the results of a medical screening examination, skills testing and my ability to provide satisfactory documentation of my U.S. citizenship or authorization to work in the U.S. within 72 hours of the commencement of my employment.

I understand that employment at (HCO) is at-will, which means that both the employer and the employee are free to terminate the employment relationship at any time, with or without notice or cause.

Print Name:

Important Information About the Application Process

Thank you for your interest in employment with (HCO). The following is information on some of the steps in the employment process:

1. The Employment Application.

All applicants for employment with (HCO) must complete the Employment Application.

2. Background Checks on Final Candidates.

3. Prior Felony Conviction Relative to a Crime of Dishonesty or a Breach of Trust.

4. Fraud Abuse and Control Information System (FACIS).

I certify that I have read the above.

Print Name:

A Summary of Your Rights Under the Fair Credit Reporting Act

Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center.

The Federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies.

You must be told if information in your file has been used against you. You have the right to know what is in your file. You have the right to ask for a credit score. You have the right to dispute incomplete or inaccurate information.

I certify that I have read the above.

Print Name:

Consumer Report -- Investigative Consumer Report Disclosure and Release Authorization

I understand that in connection with my application for employment, will obtain an Investigative Consumer Report on me for employment purposes.

I hereby give consent for an investigative consumer report to be done on me, and I hereby authorize, without reservation, any person, law enforcement agency, state agency, former employer, corporation, partnership, limited liability company, credit agency, educational institution, city, state, federal court, military institution, employer or insurance company contacted by or , to furnish any and all information required.

This authorization, in original or copy form, shall be valid for this and any further reports or updates that may be requested.

Witness my signature this (date).