Patrick County, Virginia

JOB OPPORTUNITIES:

Equal Opportunity

All applicants will be considered for employment without regard to race, religion, color, sex, national origin, marital or veteran status, medical condition or handicap, or any other status protected by law.

We are an Equal Opportunity Employer

County Government
Search by Last Name:

Administration Offices
106 Rucker Street
P.O. Box 466
Stuart, Virginia 24171
Ph: 276-694-6094
Fax: 276-694-2160

APPLICATION FOR EMPLOYMENT

Name

Last

First

Middle

Soc. Sec #
Address
City/State/Zip
Phone

Fill out this form and then press "Print Application" to see a printable version of your job application. After ensuring that the information is correct, print out the printable application, sign it, and mail or bring it to the County offices.

Are you over 18 years of age? Yes No If NO, a work permit will be required.

Are you legally eligible for permanent employment in the United States? Yes No
If hired, verification will be required by law.

Position(s) applied for	Full-time Part-time
Date Available to start	(m/d/y) - Salary or Wages desired:

Have you worked for us before? Yes No
If YES, when? Position?

Indicate special qualifications or skills relevant to position applied for:

EDUCATION:
Name & Location of School	Course of Study	Years Completed	Did you graduate?
Elementary			Yes No
High School			Yes No
College			Yes No
Other			Yes No

Are you employed at the present time? Yes No

If hired, will you work overtime if required? Yes No

Have you ever been bonded in prior employment? Yes No

If YES (above),
list name(s) of the employer(s):

Have you ever been convicted of a crime
(excluding misdemeanors and traffic offenses)?

Yes No

If YES (above), list convictions:

PRIOR EMPLOYMENT:

Employer	Phone
Address
Duties
Reason for Leaving

From	To
Position
Supervisor
Starting Salary/Wages
Final Salary/Wages

Employer	Phone
Address
Duties
Reason for Leaving

From	To
Position
Supervisor
Starting Salary/Wages
Final Salary/Wages

Employer	Phone
Address
Duties
Reason for Leaving

From	To
Position
Supervisor
Starting Salary/Wages
Final Salary/Wages

Employer	Phone
Address
Duties
Reason for Leaving

From	To
Position
Supervisor
Starting Salary/Wages
Final Salary/Wages

MILITARY SERVICE
Branch of Service	From To
Rank & Duties	Date Discharged

PERSONAL REFERENCES
Name	Address	Years Known	Telephone