Department of Human Resources

723 Woodlake Drive
Chesapeake, VA23320

Office (757) 420-4700
FAX (757) 965-9528

APPLICATION FOR EMPLOYMENT

SPSA is an Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, age, color, religion, sex, religion, national origin, disability, genetic information, marital status, or sexual orientation.

PERSONAL INFORMATION

Position Applied For:

Location:

Location 2:

Name:

Address:

Email:

Primary Contact Number:

select one:
homeworkcell

Alternate Contact Number:

Best time to reach you:

Yes
No

Are you currently employed by SPSA?
YesNo

Have you ever been employed by SPSA? If Yes, please give dates of last employment:

YesNo

Do you have any relatives currently employed by SPSA? If Yes, please give name, relationship, and department:
YesNo

Are you eligible to work in the United States?

(if offered employment, you will be required to provide documentation to verify eligibility)
YesNo

COMPUTER SKILLS

Indicate Software Skills & Proficiency level:

Circle one, if applicable:
Word
BegIntmdAdv

Excel
BegIntmdAdv

Access
BegIntmdAdv

Power Point
BegIntmdAdv

List any additional software experience:

No previous computer/software experience
No

EDUCATIONAL BACKGROUND

Mark highest level completed:

High School
123456789101112

Received (check one, if applicable)
DiplomaGED

College
1234

Graduate
12

Name of High School:

Name of College/University

Location

Hours Completed

Degree Earned

Major or Specialty

Other (i.e., vocational, technical, business, etc.)

LICENSES AND CERTIFICATIONS

List any licenses/certifications or other authorization you possess to practice a trade or profession (CPA, CPR, PE, etc.) including state and expiration date:

State

Expiration

Indicate type of Driver’s License:
StandardCommercial (CDL)Class

EMPLOYMENT AND VOLUNTEER EXPERIENCE

The Application for Employment and any Supplemental Experience Form(s) must be completed. Starting with your most recent position, describe all paid, military, or applicable volunteer experience, as well as any periods of unemployment, including reasons for unemployment. Describe those duties and responsibilities which best demonstrate your qualifications for this position. Omission of any items means you might not receive full consideration for a position in which this information is needed.

Job Title:

Immediate Supervisor:

Employer:

Address:

Phone:

Dates of Employment:

Salary:

May we contact this employer?
YesNo

Reason for Leaving:

Hours/Week:
Full-TimePart-Time

Description of Job Duties (DO NOT use “see resume”):

Job Title:

Immediate Supervisor:

Employer:

Address:

Phone:

Dates of Employment:

Salary:

May we contact this employer?
YesNo

Reason for Leaving:

Hours/Week:
Full-TimePart-Time

Description of Job Duties (DO NOT use “see resume”):

Job Title:

Immediate Supervisor:

Employer:

Address:

Phone:

Dates of Employment:

Salary:

May we contact this employer?
YesNo

Reason for Leaving:

Hours/Week:
Full-TimePart-Time

Description of Job Duties (DO NOT use “see resume”):

Job Title:

Immediate Supervisor:

Employer:

Address:

Phone:

Dates of Employment:

Salary:

May we contact this employer?
YesNo

Reason for Leaving:

Hours/Week:
Full-TimePart-Time

Description of Job Duties (DO NOT use “see resume”):

Job Title:

Immediate Supervisor:

Employer:

Address:

Phone:

Dates of Employment:

Salary:

May we contact this employer?
YesNo

Reason for Leaving:

Hours/Week:
Full-TimePart-Time

Description of Job Duties (DO NOT use “see resume”):

ACKNOWLEDGMENT AND CERTIFICATION

  • I acknowledge that I have read and understand the job description and the physical requirements for this position.
  • If employment is offered by SPSA, such employment shall be conditional upon successful completion of a job-related physical, drug screen and criminal background check.

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 SPSA to verify their accuracy and to obtain reference information on my work performance. I hereby release SPSA 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 the SPSA. 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 SPSA may terminate my employment at any time with or without notice or cause.

Applicant Signature

Date

Upload/attach a resume:

Upload/attach a cover letter:

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