Application

Position(s) Applied For*
Availability*
- Full-Time
- Part-Time
Personal Information
Name*
Prefix First Middle Last Suffix
Present Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Sex*
- Male
- Female
Date of Birth*
Date Format: MM slash DD slash YYYY

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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. Use additional attachments if necessary.
Work History
Job Experience
Job Title
Employer Address
Street Address Address Line 2 City State ZIP Code

Phone
Full-Time, Part-Time, or Both?
Full-Time
Part-Time
Years @ Full-Time
Months @ Full-Time
Years @ Part-Time
Months @ Part-Time
If part-time, number of hours worked per week
Type of Business
Immediate Supervisor
Title
Start Date
Date Format: MM slash DD slash YYYY

Starting Salary
Last Date Worked
Date Format: MM slash DD slash YYYY

Final Salary
Duties
Number of employees supervised
Equipment Used
Reason for Leaving
Name (if different)
Can we contact this employer?
Yes
No
Additional Attachments (if any)

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List three persons who are not related to you who know your qualifications or your character.
References
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code

Phone
Relationship
Occupation

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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
Please note the type of violation(s)*
- Felony
- Misdemeanor
- Traffic (moving) violation - excluding minor traffic violations
Offenses*
Description of offense Date of charge Date of conviction County, 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?*
Date Format: 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

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Certification
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 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*
Date Format: MM slash DD slash YYYY
Signature of Applicant*

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Personal Information

Education / Qualifications

Licenses

Experience

Work History

Miscellaneous

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.

Certification

Invitation to Self-Identify

Description of offense	Date of charge	Date of conviction	County, City, and State of Conviction