TOWN OF PURCELLVILLE

2. APPLICATION FOR EMPLOYMENT

4. 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.

6. First Name*

7. Last Name*

9. Address1*

11. Address2

13. City*

14. State*

15. Zip*

17. Email Address*

18. Phone number*

19. Type*
    -- Select One --CellWorkHome

21. Position applied for:*
    -- Select One --Lab TechnicianPolice Sergeant

23. How did you learn about us?
    -- Select One --Town websiteNewspaper AdFriend/RelativeSocial MediaEmployment AgencyIndeed.comVML.orgICMA.orgOther

25. If under the age of 18, can you provide the required proof of your eligibility to work?*

    1. Yes
    2. No
27. For the purpose of compliance with the United States Immigration and Nationalization Act, 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.*

    1. Yes
    2. No

29. Have you ever filled out an application with the Town of Purcellville before?*

    1. Yes
    2. No

30. If Yes, please give date of application:

32. Have you ever been employed with the Town of Purcellville before?*

    1. Yes
    2. No

33. If Yes, please give date of employment:

35. Are you currently employed?*

    1. Yes
    2. No

36. May we contact your current employer?*

    1. Yes
    2. No

38. Have you ever been fired or resigned from a position after being notified you were fired?*

    1. Yes
    2. No

39. If Yes, please explain:*

41. Interested in:*

    1. Full Time
    2. Part Time

42. Date you are available for work:*
    Date you are available for work:

43. What is your desired salary range?*

45. Do you have a valid Drivers License?*

    1. Yes
    2. No

46. Please list the Drivers License Number/State/Expiration Date:

48. Can you travel if the job requires it?*

    1. Yes
    2. No

50. Are you currently on "lay off" status and subject to recall?*

    1. Yes
    2. No

52. EDUCATION
    Please list all types that apply.

    Please list all types that apply.

54. School Type*
    -- Select One --High School (or highest grade completed)College or UniversityGraduate or Professional SchoolBusiness or Trade SchoolOther

55. School Name and Location*

57. Degree or # of Credits Completed*

58. Course of Study*

59. Add another School

    1. +

61. School Type*
    -- Select One --High School (or highest grade completed)College or UniversityGraduate or Professional SchoolBusiness or Trade SchoolOther

62. School Name and Location*

64. Degree or # of Credits Completed*

65. Course of Study*

66. Add another School

    1. +

68. School Type*
    -- Select One --High School (or highest grade completed)College or UniversityGraduate or Professional SchoolBusiness or Trade SchoolOther

69. School Name and Location*

71. Degree or # of Credits Completed*

72. Course of Study*

73. Add another School

    1. +

75. School Type*
    -- Select One --High School (or highest grade completed)College or UniversityGraduate or Professional SchoolBusiness or Trade SchoolOther

76. School Name and Location*

78. Degree or # of Credits Completed*

79. Course of Study*

81. WORK EXPERIENCE
    Please list your current or last employer first, including related military service or volunteer work.

    Please list your current or last employer first, including related military service or volunteer work.

83. Employer*

84. Supervisor Name / Phone*

86. Address*

87. City, State*

88. Zip code

90. Position Held*

91. # of Hours per Week*

92. Starting Salary*

93. Final Salary*

95. Is this your current employer?*

    1. Yes
    2. No

96. Start Date*
    Start Date

97. Dates Employed*
    Dates Employed Start Date

    —

    Dates Employed End Date

99. Reason for seeking new employment?*

100. Reason for Leaving*

102. Description of Work*

104. Add another Employer

     1. +

106. Employer*

107. Supervisor Name / Phone*

109. Address*

110. City, State*

111. Zip code

113. Position Held*

114. Reason for Leaving*

115. # of Hours per Week*

117. Dates Employed*
     Dates Employed Start Date

     —

     Dates Employed End Date

118. Starting Salary*

119. Final Salary*

121. Description of Work*

123. Add another Employer

     1. +

125. Employer*

126. Supervisor Name / Phone*

128. Address*

129. City, State*

130. Zip code*

132. Position Held*

133. Reason for Leaving*

134. # of Hours per Week*

136. Dates Employed*
     Dates Employed Start Date

     —

     Dates Employed End Date

137. Starting Salary*

138. Final Salary*

140. Description of Work*

142. Add another Employer

     1. +

144. Employer*

145. Supervisor Name / Phone*

147. Address*

148. City, State*

149. Zip code

151. Position Held*

152. Reason for Leaving*

153. # of Hours per Week*

155. Dates Employed*
     Dates Employed Start Date

     —

     Dates Employed End Date

156. Starting Salary*

157. Final Salary*

159. Description of Work*

163. Please explain any gaps in employment history

165. Please list any Awards or Certifications

167. Specialized training, apprenticeship and/or skills and abilities received in the United States Military or elsewhere

169. 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)

171. Office/Computer Skills (check all that apply)

     1. PC / Mac
     2. Word Processing

     1. Spreadsheets
     2. Database software

     1. Graphs, Presentations
     2. Outlook Mail/Calendar

     1. Dictation
     2. Shorthand

173. Additional information you feel may be helpful to us in considering your application

175. REFERENCES
     Personal or Professional References (please do not include family members or past supervisors)

     Personal or Professional References (please do not include family members or past supervisors)

177. Name

178. Phone #

179. Best time to call

180. Relationship

182. Name

183. Phone #

184. Best time to call

185. Relationship

187. Name

188. Phone #

189. Best time to call

190. Relationship

192. APPLICANT'S STATEMENT
     Please read carefully before signing

     Please read carefully before signing

194. 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.

196. 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.

198. 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.

200. 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.

202. I understand that I am required to abide by all rules and regulations of the employer.

206. Applicant Signature*

207. Applicant Initials*

208. Date*
     Date

210. By entering my signature and initials above I authorize this digital signature to be used as my signature

     1. *

212. File Upload - Resume

213. File Upload - Other

Leave This Blank:


215. 1. Receive an email copy of this form.
216. Email address

     This field is not part of the form submission.

217. Submit Submit and Print

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