Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
*
(###)
###
####
Date available to start
*
MM
DD
YYYY
Preferred Location
*
Timberlake - Lynchburg
Wards Road - Lynchburg
Linkhorne - Lynchburg
Lakeside - Lynchburg
Appomattox
Bedford
Altavista
Forest
No preference
Type of work applying for
*
Full time
Part time
Temporary
Flexible
Attendance
*
Are you able to meet the attendance requirements?
Overtime
*
Do you have any objection to working overtime if necessary?
Travel
*
Can you travel if required by this position?
Former Employment
*
Have you ever been previously employed by our organization?
Identity
*
Can you submit proof of legal employment authorization and identity?
Eligibility
*
If you are under 18, can you furnish a work permit if it is required?
Convictions
*
Have you ever been convicted of a crime in the last 7 years? If yes, please explain in the space below (a conviction will not automatically bar employment):
Conviction Explanation
Employment 1
*
Employment 1 Position Held
Employment 1 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employment 1 Phone
(###)
###
####
Employment 1 Immediate Supervisor and Title
Employment 1 Start Date
MM
DD
YYYY
Employment 1 End Date
MM
DD
YYYY
Employment 1 Job Summary
Employment 1 Reason for Leaving
Employment 2
Employment 2 Position Held
Employment 2 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employment 2 Phone
(###)
###
####
Employment 2 Immediate Supervisor and Title
Employment 2 Start Date
MM
DD
YYYY
Employment 2 End Date
MM
DD
YYYY
Employment 2 Job Summary
Employment 2 Reason for Leaving
Skills and Qualifications
*
Tell us about yourself, your job-related trainings, skills, licenses, certifications and other qualifications.
Education
*
Tell us about your High School, College, Technical Training and any other education or scholastic achievements including graduation year.
Availability
*
What days are you available to work? Check all that apply.
Authorization
*
By checking this box, you hereby authorize the potential employer to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, and references. I also hereby release from liability the potential employer and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.
I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.
If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or the employer can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.
I understand that it is the policy of this organization not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA.
I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.
I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.
Today's Date
*
MM
DD
YYYY
Additional Comments
Help us to get to know you. Tell us about yourself, your passions and your dreams.
