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POSITION INFORMATION - ONE POSITION PER APPLICATION!  CLICK HERE FOR CURRENT POSITION OPENINGS
Position Applied for    Position Number   Deadline

FT  PT  (As Posted)

 
Department of Human Resources
County of Roanoke Virginia
P.O. Box 29800
Roanoke, Virginia 24018-0798
(540)772-2018     FAX(540) 776-7130
APPLICATION FOR EMPLOYMENT

To Applicant:
Employees of Roanoke County and applicants for employment shall be afforded equal employment opportunity in all respects of employment without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender or age.

APPLICANT INFORMATION
Social Security Number
   First Middle Last
Street
City  State         Zip  
Phone Email

EDUCATION / QUALIFICATIONS

High

School

Please choose highest grade completed

High School Diploma? Yes No   State of Issue
H. S. Equivalency Diploma?  Yes No Date Rec'd   State of Issue 

Post

High

School

 Number of years of post-high school education
Name & Location Degree Rec'd Major or 
Specialty 		Minor Dates Attended

ADDITIONAL TRAINING (Including business, trade, armed forces, correspondence or night school)
Name of School Subject Duration of Course Did you Finish?

Certificate
 Awarded
yes no
yes no
yes no

ADDITIONAL QUALIFICATIONS

Please describe any additional skills or qualifications that are relevant to the position for which you are applying, including any certifications

Do you have a valid drivers license? Yes   No     Licensing State 
Do you have a valid CDL license?   Yes     No      CDL State  
List CDL Class    List CDL Endorsements   

EXPERIENCE
Starting with the most recent, describe all paid, military and applicable voluntary experience. Highlight the knowledge, skills, and abilities that demonstrate your qualifications for this position. 
A Job Title  
Employer  
  Type of Business
  Street 
   City
  ST
Phone 
Immediate  
Supervisor		    Title
Salary (Start) Salary (Final) 
Dates (mm/yy)   To (mm/yy)     
Duties   Equipment used
Number employees supervised
Reason for Leaving
Name, if different
B Job Title  
Employer  
  Type of Business
  Street 
   City
  ST
Phone 
Immediate  
Supervisor		    Title
Salary (Start) Salary (Final) 
Dates (mm/yy)   To (mm/yy)     
Duties   Equipment used
Number employees supervised
Reason for Leaving
Name, if different
C Job Title  
Employer  
  Type of Business
  Street 
   City
  ST
Phone 
Immediate  
Supervisor		    Title
Salary (Start) Salary (Final) 
Dates (mm/yy)   To (mm/yy)     
Duties   Equipment used
Number employees supervised
Reason for Leaving
Name, if different
D Job Title  
Employer  
  Type of Business
  Street 
   City
  ST
Phone 
Immediate  
Supervisor		    Title
Salary (Start) Salary (Final) 
Dates (mm/yy)   To (mm/yy)     
Duties   Equipment used
Number employees supervised
Reason for Leaving
Name, if different
E Job Title  
Employer  
  Type of Business
  Street 
   City
  ST
Phone 
Immediate  
Supervisor		    Title
Salary (Start) Salary (Final) 
Dates (mm/yy)   To (mm/yy)     
Duties   Equipment used
Number employees supervised
Reason for Leaving
Name, if different
May we contact the employers listed above? Yes No
If No, please indicate by letter/number which one(s) you do not wish for us to contact

Additional Experience not covered above:  

REFERENCES
List three persons who are not related to you who know your qualifications or your character
Name Address Phone Relationship Occupation

MISCELLANEOUS
Other than violations committed as a juvenile (under 18 years of age),
have you ever been convicted of any violation(s) of the law?    Yes No

TYPE OF VIOLATION

  Felony
Yes   No

 Misdemeanor
Yes   No  		Moving Traffic Violation
(excluding minor traffic violations)
Yes No 
Description of the offense(s)  
Date of charge(s)

  Date of conviction(s)  
County City State
If you have more than one reportable violation, please enter additional  information below
  including Type, Description, Dates, County/City and State:
For purposes of compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States?    Yes          No (Please give detailed explanation 

Under the Immigration Reform and Control Act of 1986, upon employment you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identity. In addition, you will be required to provide documentation to that effect.
Were you previously employed by Roanoke County?   No Yes   Date Left
What date will you be available for work?

EQUAL EMPLOYMENT OPPORTUNITY DATA

Roanoke County has an Affirmative Action Program to ensure equal opportunity in its hiring practices. We are asking you to help us monitor the effectiveness of our program by completing the affirmative action information below. The completion of the form is voluntary and the information will not be used for employment purposes. Your responses will be used for statistical purposes only and will be kept in a confidential file, separate from the employment application.

Federal law prohibits unlawful discrimination on the basis of race, color, sex, age, national origin, religion, or disability. As a local government employer, Roanoke County complies with government and equal employment regulations.

How did you find out about this employment opportunity?

Roanoke County Website
Other Website (please specify)  
Newspaper (please specify)    
Employee Referral
Employment Agency (please specify)    
Other (please specify)    
Previous Employment
Radio
VEC
I agree to provide Equal Employment Opportunity information
I decline to provide Equal Opportunity Employment information.
 
Please click the appropriate block.   Male      Female
 
Please select month of birth
Please enter day of birth
Please enter 4 digit year of birth

Please select one of the following Race/Ethnic Groups:


Please select the highest level of education you have completed.
  Less than 8th grade
  Completed 8th Grade
  Attended High School
  High School Graduate or equivalent
  Attended College
  College Graduate   
  Attended Grad School
  Masters Degree
  Graduate study beyond master's requirements
  Ph.D. or professional degree
 
Are you a veteran ?  Yes    No    
CERTIFICATION

By clicking submit below, I certify that all information provided on this application is true, accurate and complete. I understand that the falsification, misrepresentation or omission of facts on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered. 

I understand that all information on this application is subject to verification and I consent to criminal history and driving record background checks, if applicable. I further understand that I may have to pass a physical examination as a condition of my employment and that I may be required to provide a copy of my driving record. You are authorized to execute an affidavit for release of information from references, former employers and educational institutions regarding this application. I hereby release Roanoke County from any/all liability of whatever kind and nature resulting from obtaining and having an employment decision based on such information. 

I acknowledge that I have read and understand the above statements and by submission of this application hereby grant permission to confirm the information supplied on this application.

I agree to the conditions of the above certification
Use the scroll arrows to REVIEW YOUR APPLICATION. Make any change desired by typing over the old information.  You will be required to sign a paper copy if you are interviewed. This will become an official, permanent record. 
    You may print this page before submitting if you wish, by clicking the Print button.  
Please remember to click the Submit button below after printing! 

Please click submit only once!  It may take a few minutes for your application to submit, so please be patient.  We recommend that you print the confirmation page that appears after clicking submit.  You will need the confirmation number that is shown at the top if you have questions about your application.