32 Park Boulevard, Staunton, VA 24401 (540) 886-7372
EMPLOYMENT / JOB APPLICATION
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.
PERSONAL INFORMATION
FULL NAME: ___________________________________ DATE: __________________
First Middle Last
ADDRESS: _____________________________________________________________
Street Address Apt/Suite
_____________________________________________________________
City State Zip Code
E-MAIL: __________________________________ PHONE: _____________________
SOCIAL SECURITY NUMBER (SSN): _____-____-_____
DATE AVAILABLE: __________________
POSITION APPLIED FOR: _________________________________________________
EMPLOYMENT DESIRED: ☐ FULL-TIME ☐ PART-TIME ☐ SUBSTITUTE
EMPLOYMENT ELIGIBILITY
ARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S? ☐ YES ☐ NO*
HAVE YOU EVER WORKED FOR THIS EMPLOYER? ☐ YES* ☐ NO
*IF YES, WRITE THE START AND END DATES: ____________________________________
HAVE YOU EVER BEEN CONVICTED OF A FELONY? ☐ YES* ☐ NO
*IF YES, PLEASE EXPLAIN: ____________________________________________________
____________________________________________________________________________
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EDUCATION
HIGH SCHOOL: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
GRADUATE? ☐ YES ☐ NO DIPLOMA: _____________________
COLLEGE: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
GRADUATE? ☐ YES ☐ NO DEGREE: _____________________
OTHER: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
OTHER: _____________________ CITY / STATE: _____________________
FROM: _____________________ TO: _____________________
DEGREE/CERTIFICATION: _____________________
PREVIOUS EMPLOYMENT
EMPLOYER 1: __________________________________________________________
Company / Individual
E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Street Address Apt/Suite
____________________________________________________________
City State Zip Code
JOB TITLE: ______________ RESPONSIBILITIES: _____________________________
FROM: _____________________ TO: _____________________
REASON FOR LEAVING: _______________________________________________________
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EMPLOYER 2: __________________________________________________________
Company / Individual
E-MAIL: __________________________________ PHONE: _____________________
ADDRESS: ____________________________________________________________
Street Address Apt/Suite
____________________________________________________________
City State Zip Code
JOB TITLE: ______________ RESPONSIBILITIES: _____________________________
FROM: _____________________ TO: _____________________
REASON FOR LEAVING: _______________________________________________________
REFERENCES
FULL NAME: _______________________________ RELATIONSHIP: ______________
First Last
COMPANY: ________________________________ TITLE: ______________
E-MAIL: __________________________________ PHONE: _____________________
FULL NAME: _______________________________ RELATIONSHIP: ______________
First Last
COMPANY: ________________________________ TITLE: ______________
E-MAIL: __________________________________ PHONE: _____________________
FULL NAME: _______________________________ RELATIONSHIP: ______________
First Last
COMPANY: ________________________________ TITLE: ______________
E-MAIL: __________________________________ PHONE: _____________________
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MILITARY SERVICE
ARE YOU A VETERAN? ☐ YES ☐ NO
BRANCH: _____________________ RANK AT DISCHARGE: _____________________
FROM: _____________________ TO: _____________________
TYPE OF DISCHARGE: _____________________
IF NOT HONORABLE, PLEASE EXPLAIN: ______________________________________
FIRST AID CERTIFICATION? YES NO Expiration Date: _________________
CPR CERTIFICATION? YES NO Expiration Date: _________________
BACKGROUND CHECK CONSENT
IF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK? ☐ YES ☐ NO
DISCLAIMER
Applicant understands that this is an Equal Opportunity Employer and committed to excellence
through diversity. In order to ensure this application is acceptable, please print or type with the
application being fully completed in order for it to be considered.
Please complete each section EVEN IF you decide to attach a resume.
I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this
application leads to my eventual employment, I understand that any false or misleading
information in my application or interview may result in my employment being terminated.
SIGNATURE _________________________________ DATE _____________________
PRINT NAME _________________________________
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