Application 1Personal Information2Education / Qualifications3Experience / Work History4References & Residences5Miscellaneous6Certification7Invitation to Self-Identify Position(s) Applied For* Availability* Full-Time Part-Time Personal InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Present Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Sex* Male Female Date of Birth* MM slash DD slash YYYY Education / QualificationsPlease check highest grade completed* 1 2 3 4 5 6 7 8 9 10 11 12 High School Diploma?* Yes No State of Issue* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State High School Equivalency Diploma?* Yes No State of Issue* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Date Received* MM slash DD slash YYYY Please check number of years of post-high school education 1 2 3 4 5 6 7 College DegreesName & Location of Institution Degree Received Major or Specialty Minor Dates Attended Add DegreeRemove Degree Additional TrainingName of School Subject Duration of Course Did you finish? Yes No Certificate awarded? Yes No Add ItemRemove ItemAdditional QualificationsPlease describe any additional skills or qualifications that are relevant to the position for which you are applying, including any certifications.LicensesDo you have a valid driver's license?* Yes No State of Issue* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Do you have a valid Commercial Driver's License?* Yes No State of Issue* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State List Class* List Endorsements (if any) ExperienceStarting 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. Use additional attachments if necessary.Work History Job ExperienceJob Title Employer Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFull-Time, Part-Time, or Both? Full-Time Part-Time Years @ Full-TimeMonths @ Full-TimeYears @ Part-TimeMonths @ Part-TimeIf part-time, number of hours worked per weekType of Business Immediate Supervisor Title Start Date MM slash DD slash YYYY Starting SalaryLast Date Worked MM slash DD slash YYYY Final SalaryDutiesNumber of employees supervisedEquipment Used Reason for Leaving Name (if different) Can we contact this employer? Yes No Add JobRemove JobAdditional Attachments (if any)Max. file size: 100 MB. List three persons who are not related to you who know your qualifications or your character. ReferencesName First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneRelationship Occupation Add ReferenceRemove Reference MiscellaneousOther 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 Please note the type of violation(s)* Felony Misdemeanor Traffic (moving) violation - excluding minor traffic violations Offenses*Description of offenseDate of chargeDate of convictionCounty, City, and State of Conviction For purposes of compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States?* Yes No 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 NRVRJ?* Yes No When?* What date will you be available for work?* MM slash DD slash YYYY New River Valley Regional Jail monitors its advertising sources to ensure our employment opportunities are posted with sources utilized most often by prospective applicants. Please tell us how you heard about this employment opportunity.How did you find out about this employment opportunity?* Internet Employment Agency NRVRJ Website Other Other Source Newspaper Previous Employment Employee Referral Radio VEC (VA Employment Commission) Please Specify* Please check the block for 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 graduate school Master's degree Graduate study beyond master's requirements Ph.D. or professional degree CertificationI 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 the New River Valley Regional Jail 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.Date* MM slash DD slash YYYY Signature of Applicant* Invitation to Self-IdentifyThis company is subject to Executive Order 112 46, as amended, which requires Federal contractors to ensure t hat applicants a re employed and that employees are treated during employment without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. We are therefore requesting information about race and gender in order to comply with government reporting requirements and in order to ensure equal employment opportunity. Submission of this information is voluntary and will be kept confidential. Refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with Federal affirmative action regulations.Name First Last Date MM slash DD slash YYYY Position Birth Date MM slash DD slash YYYY Male Female I Choose Not To Self-Identify White Black or African American Asian American Indian / Alaska Native Native Hawaiian or Pacific Islander Two or More Races I Choose Not To Self-Identify Do you consider yourself Hispanic or Latino? Yes No This company is also subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment veterans in the following classifications: A “disabled veteran” is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability. A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE I AM NOT A PROTECTED VETERAN
