Form Center

2. 

3. Scott County, VA - Application for Employment

   • Follow instructions carefully
   • Provide detail – do not use “see resume”
   • If accommodation or assistance is needed in completing this application, contact the county offices.
7. Position Applying For*
9. Name*
10. Email Address
12. Address*
14. City*
15. State*
16. Zip Code*
18. Phone Number*
20. Have you ever been employed in any agency, department, board or commission of Scott County?*

    1. Yes
    2. No
21. If so, please state dates of employment:
    If so, please state dates of employment: Start Date

    —

    If so, please state dates of employment: End Date
22. Agency, Department, Board or Commission to Which you were Employed
24. Are eligible to work in the United States?*

    1. Yes
    2. No
25. How did you learn about this opening?
27. VA Code Section 2.2-2804 prohibits employment by any political subdivision of the Commonwealth of Virginia of a person who was required to present himself and submit to federal Selective Service registration requirement and failed to do so. If you were required to register for Selective Service, have you done so?*

    1. Yes
    2. No
    3. NA
31. Did you graduate high school or earn a GED?*

    1. Yes
    2. No
32. If Yes, What year?
33. If No, Highest Grade Earned?
37. Higher / advanced learning or training 1
39. SCHOOL NAME AND LOCATION (college, business, vocational, or other)
40. Field, Trade, Major
42. Did you Graduate?

    1. Yes
    2. No
43. Diploma, Degree, Certificate earned & and year received.
45. Higher / advanced learning or training 2
47. SCHOOL NAME AND LOCATION (college, business, vocational, or other)
48. Field, Trade, Major
50. Did you Graduate?

    1. Yes
    2. No
51. Diploma, Degree, Certificate earned & and year received.
53. Higher / advanced learning or training 3
55. SCHOOL NAME AND LOCATION (college, business, vocational, or other)
56. Field, Trade, Major
58. Did you graduate?

    1. Yes
    2. No
59. Diploma, Degree, Certificate earned & and year received.
63. License or Certification 1

    List all current and expired certifications which would pertain to the position you are applying for.

65. License/Certification
66. State
67. Profession
69. License/Certification #
70. Expiration Date
72. License or Certification 2
74. License/Certification
75. State
76. Profession
78. License/Certification #
79. Expiration Date
81. License/Certification 3
83. License/Certification
84. State
85. Profession
87. License/Certification #
88. Expiration Date
90. License/Certification 4
92. License/Certification
93. State
94. Profession
96. License/Certification #
97. Expiration Date
101. Employment History:
     • Start with your current or last job – include armed forces service andself-employment.
     • Any change of job title under the same employer should be considered a separate position.
     • Provide detail; do not use “see resume” or leave out information. Write NA in blocks that are not applicable.
103. Employer 1
105. Employer
106. Telephone Number
107. Supervisor's Name
109. Type of Business
110. Address
112. Job Title
113. Dates Employed
     Dates Employed Start Date

     —

     Dates Employed End Date
114. Average Hours Worked Per Week
116. Duties
118. Monthly Salary
119. Reason for Leaving or Reason for Considering Leaving if Still Employed
121. Employer 2
123. Employer
124. Telephone Number
125. Supervisor's Name
127. Type of Business
128. Address
130. Job Title
131. Dates Employed
     Dates Employed Start Date

     —

     Dates Employed End Date
132. Average Hours Worked Per Week
134. Duties
136. Monthly Salary
137. Reason for Leaving or Reason for Considering Leaving if Still Employed
139. Employer 3
141. Employer
142. Telephone Number
143. Supervisor's Name
145. Type of Business
146. Address
148. Job Title
149. Dates Employed
     Dates Employed Start Date

     —

     Dates Employed End Date
150. Average Hours Worked Per Week
152. Duties
154. Monthly Salary
155. Reason for Leaving or Reason for Considering Leaving if Still Employed
159. Skills and Talents

     List any special skills or talents which you could utilize in the position for which you are applying:

163. References

     Identify three individuals who know you well enough to validate your personal attributes such as integrity and passion and to attest to your academic or professional strengths.

165. Reference 1
167. Name
168. Address
170. Home/Mobile Phone
171. Work Phone
172. Email
174. How does this person know you?

     (coworker, friend, pastor, etc.)

176. Reference 2
178. Name
179. Address
181. Home/Mobile Phone
182. Work Phone
183. Email
185. How does this person know you?

     (coworker, friend, pastor, etc.)

187. Reference 3
189. Name
190. Address
192. Home/Mobile Phone
193. Work Phone
194. Email
196. How does this person know you?

     (coworker, friend, pastor, etc.)

200. Resume
202. Please upload Resume
206. Additional Infomation

     Please enter any additional Employment History, Education, Training, License or Certifications you may have

208. I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Scott County to verify their accuracy and to obtain reference information on my work performance. I consent to a criminal history background check. I hereby release Scott County from any/all liability of whatever kind and nature which, at any time, could result from obtaining and basing an employment decision on such information.

     I understand that falsified statements of any kind or omissions of facts called for on this application may result in disqualification for consideration for employment or, if already employed, grounds for immediate dismissal.

     I understand that should an employment offer be extended to me and accepted, I will fully adhere to the policies, rules and regulations of employment of Scott County. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or Scott County may terminate my employment at any time with or without notice or cause.

     • All information provided is subject to the Virginia Freedom of Information Act (FOIA), located at § 2.2-3700 et seq. of the Code of Virginia.
     • Scott County is an EOE (equal opportunity employer) and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.
     • Applications submitted in response to an advertised position vacancy will be retained three (3) years.
     • Applications which are submitted when no position has been announced will be retained for six (6) months.
     • Fill in all requested information. If an application is submitted with a line or section with incomplete information or filled out incorrectly may be discarded. In all sections that do not apply to you write NA (Not applicable).
Leave This Blank:


210. 1. Receive an email copy of this form.
211. Email address

     This field is not part of the form submission.

212. Submit

* indicates a required field