Employment Application

8716 West Broad Street Richmond, VA 23294-6206 (804) 270-6566

PERSONAL INFORMATION

Social Security No:

Name:

Present Address:

Home Phone No:

Alternate Phone No:

E-mail Address:

Are you legally eligible for employment in the United States?

Do you have a Valid Driver's License?

Issuing State:

Are you currently employed?

How did you hear about the Virginia Home for Boys & Girls?

Richmond Times-Dispatch	Monster.com
Other newspaper
Teaching-Family.org	Employee reference
Other, please specify:

Who referred you?

Which position are you applying for?

Salary expectation:

Have you ever applied for a job with Virginia Home for Boys & Girls? If yes, when?

Were you previously employed by Virginia Home for Boys & Girls? If yes, when?

Do you have any relatives working for Virginia Home for Boys & Girls?

Are you at least 18 years of age?

Have you ever been:

1. Convicted of a violation of law? (This includes, but is not limited to, misdemeanors, felonies, driving while intoxicated or moving violations, even if no time was served.)

2. Investigated by the Department of Social Services
(Child Protective Services Unit) for abuse or neglect with a result of 'founded'?)

3. Discharged from employment?

If you answered "Yes" to any of the above questions, please explain in detail. NOTE: A conviction will not necessarily disqualify an applicant from service with the Virginia Home for Boys & Girls. Factors such as age and date of the offense, the seriousness of the violation and rehabilitation will be considered

EDUCATION, SKILLS, AND TRAINING

No.	List all High School, College, University or Technical Training	Number of Years Completed	Did you Graduate?	Degree or Certificate
1.
2.
3.
4.

VOLUNTEER HISTORY

List Volunteer History involving work with youth.
No.	Organization	Position Held	Age Groups	From	To
1.

2.

3.

4.

WORK HISTORY

List Work History Beginning with the current or most recent employers. Please include all youth-related work.

No.

Company Name

Telephone Number

Position Held

From: / To:

Address

Name of Supervisor

Pay Rate

Starting: $ Last: $

City

State

Zip Code

Reason for Leaving

No.

Company Name

Telephone Number

Position Held

From: / To:

Address

Name of Supervisor

Pay Rate

Starting: $ Last: $

City

State

Zip Code

Reason for Leaving

No.

Company Name

Telephone Number

Position Held

From: / To:

Address

Name of Supervisor

Pay Rate

Starting: $ Last: $

City

State

Zip Code

Reason for Leaving

RELEASE OF REFERENCES

NAME OF APPLICANT:

NAME OF REFERENCE:

COMPANY:

Phone:

I authorize the above individual or company to furnish the Virginia Home for Boys & Girls with information regarding me including but not limited to my employment including my reason(s) for separation (termination). I am signing this release and waiver voluntarily and to request that you respond to the Virginia Home for Boys & Girls' request for reference inquiry with full and complete information. Since this is part of my application for employment with the Virginia Home for Boys & Girls, I, therefore, waive and release the above reference from all claims or causes of action in law or equity, including but not limited to, defamation of character or invasion of privacy, which might arise from responding to this reference check.

Applicant's Signature:

----------------------------------------------

Date:

NAME OF APPLICANT:

NAME OF REFERENCE:

COMPANY:

Phone:

Applicant's Signature:

----------------------------------------------

Date:

NAME OF APPLICANT:

NAME OF REFERENCE:

COMPANY:

Phone:

Applicant's Signature:

----------------------------------------------

Date:

NAME OF APPLICANT:

NAME OF REFERENCE:

COMPANY:

Phone:

Applicant's Signature:

----------------------------------------------

Date:

AVAILABILITY

What type of employment are your seeking?

Full-TimePart-TimeTemporary (less than 6 months)

How soon can you start working?

IMPORTANT

Applicant's Agreement; Read Before Signing:

1. I hereby certify that all entries on this application are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause the end of my employment with the Virginia Home for Boys & Girls.

2. I understand that all information on this application is subject to verification and I consent to investigation of references, former employers and educational institutions listed. I release all parties in this investigation from all liability as a result of releasing any information to the Virginia Home for Boys & Girls. I further authorize the Virginia Home for Boys & Girls to rely upon and use, as it sees fit, any information received from such contacts.

3. I acknowledge that any employment with the Virginia Home for Boys & Girls is "at will" and may be terminated at will for any or no reason, at any time, at the option of the agency or myself.

4. I understand that I may be required to undergo screenings for substance abuse (drugs) as a condition of my employment. I also understand that as a condition of employment, the Virginia Home for Boys & Girls will conduct extensive background checks. Falsification of information or failure to provide information can result in disqualification or termination if discovered after hire.

5. Virginia Home for Boys & Girls is an equal opportunity facility. Our policy is to consider all applicants based on their qualifications and our current opportunities. Applicants are considered without regard to race, color, religion, sex, national origin, disability, or marital status and any other category that may be protected under the applicable law.

My signature is evidence that I have read and agree with the above statement.

Applicant's Signature

Date