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Application for Employment

Augusta County Service Authority
18 Government Center Lane
PO Box 859
Verona, VA 24482
540-245-5670

Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation should notify a representative of the Human Resources Department.

Position applied for:  

Personal Information:
Name: (First) (Middle) (Last) (Suffix)
Address:   City:   State:   Zip Code:  
Country:   Home Phone Number:
Cell Phone Number:
Preferred Call Back Number:
Home  Cell
Email Address:  
Check which shift(s) you will accept:   Day   Evening   Night   Rotating   Weekends
Do any friends or relatives work for the Augusta County Service Authority?   Yes   No   If yes, please list names and relationship:
For compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States?
(Please check):  Yes   No  
Have you been employed by the ACSA before?   Yes   No   If yes, please indicate when and position.
Date available for work:   Will you work overtime/weekends/on-call if required?   Yes   No
Answering "Yes" to the below question does not constitute automatic bar to employment. Factors such as date of offense, seriousness, nature of violation, and position in which you are applying will be taken into consideration.

Have you ever pled "guilty", "no contest", and/or been convicted for any violation of law, including moving traffic violations?   Yes   No   If yes, please explain in the space below.

Offense: Date of Charge: Date of Conviction: Location of Conviction:

Educational Information:
Indicate highest grade completed:
  
If you did not complete high school, do you have a high school equivalency diploma?   Yes   No  
Indicate number of years of post high school education:  

Educational Institutions:
Name of School and Location:
Credit/Hours:   Degree if applicable:  
Major of Specialty if applicable:   Minor if applicable:  
Begin date:   End date (leave blank if still attending):  

Name of School and Location:
Credit/Hours:   Degree if applicable:  
Major of Specialty if applicable:   Minor if applicable:  
Begin date:   End date (leave blank if still attending):  

Name of School and Location:
Credit/Hours:   Degree if applicable:  
Major of Specialty if applicable:   Minor if applicable:  
Begin date:   End date (leave blank if still attending):  

Work Experience:
Please begin with most recent employer and list all employment including paid, internships, and volunteer work experience. Please also explain any gaps in employment.

Employer Name and Address:
Dates Employed:
From:  
To:  
Job Title:
Starting Pay:
Most Recent/Ending Pay:
Duties:
Supervisor's Name:
Supervisor's Title:
Phone:
Hours per week:
Type of Business:
Your name if different from present:
Number of employees you supervised:
Equipment used:
Type of Employment:
Reason for Leaving:
May we contact for a reference?
  Yes   No   Later

Employer Name and Address:
Dates Employed:
From:  
To:  
Job Title:
Starting Pay:
Most Recent/Ending Pay:
Duties:
Supervisor's Name:
Supervisor's Title:
Phone:
Hours per week:
Type of Business:
Your name if different from present:
Number of employees you supervised:
Equipment used:
Type of Employment:
Reason for Leaving:
May we contact for a reference?
  Yes   No   Later

Employer Name and Address:
Dates Employed:
From:  
To:  
Job Title:
Starting Pay:
Most Recent/Ending Pay:
Duties:
Supervisor's Name:
Supervisor's Title:
Phone:
Hours per week:
Type of Business:
Your name if different from present:
Number of employees you supervised:
Equipment used:
Type of Employment:
Reason for Leaving:
May we contact for a reference?
  Yes   No   Later

Please List Three (3) References Other Than Relatives:
Name and Address: Phone Number: Email: Relationship:

Additional Information:
Please use this space for any additional information you think would help us evaluate your application including professional licenses, special training, skills, professional/trade/business/civic associations, and/or certificates/awards that may qualify you as being able to perform the job-related functions in the position for which you are applying. Exclude memberships that would reveal race, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve National Guard or any similarly protected status.
Please indicate how you learned about this opportunity?  

Licenses:
Do you have a valid driver's license?     Yes   No
Do you have a Commercial Driver's License (CDL)?     Yes   No
If yes, please specify class and any endorsements.  

Resume Upload:
Please use this field to upload a resume [Microsoft Word (.doc, .docx), Adobe PDF (.pdf), Plain Text (.txt), or Rich Text (.rtf) only]
Applicant Statement:
I certify that all information I have provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application; or (ii) immediately discharge me from the employer’s service whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to conduct a criminal record search and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. However, I understand that this application may continue to be active throughout the duration of the hiring process for the specific position in which I have applied if that takes longer than 30 days.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.
By typing my name, I consent to this being considered an electronic signature and, I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Name:  Date:  

Please only press "Submit Application" once.