Social Security No.

Full legal name

Home phone

Address

Other phone

City

State

Zip

E-mail Address

EDUCATION

Check highest grade completed 123456789101112

If you did not complete high school, do you have a high school equivalency diploma? YesNo

Check number of years of post high school education? 1234567

If you expect to complete an educational program in the near future, please indicate what type of degree or program are expected

EXPERIENCE

Use Supplementary Experience Form(s) for additional space. Starting with the most recent, describe ALL paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position. You may list significally different jobs within the same organization as separate items.

May we contact your present supervisor? YesNo

Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, and special achievements or specialiazed skills:

Automated word processing (specify equipment):

Typing speed, words per minute

Shorthand speed, words per minute

License (to include driver's), certificate or other authorization to practice a trade or profession.

REFERENCES

List names, addresses and relationships of three persons not related to you who know your qualifications:

MISCELLANEOUS

For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the united States? YesNo

Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identify. Further, you will be required to provide documentation to that effect should you be employed.

Section 2.2-2804 of the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality of the Commonwealth from employing a person who required to present himself and submit to federal Selective Service registration requirement and failed to do so.

If you are/were required to register for the Selective Service, have you done so? YesNo

If no, state reason:

For purposes of compliance with Section 2.2-2903 of the Code of Virginia, are you a veteran who received an honorable discharge and has (i) provided more than 180 consecutive days of full-time active- duty in the armed forces of the United States or reserve components thereof, including the National the National Guard, or (ii) has a service-connected disability rating fixed by the United States Veterans Affairs? YesNo

If yes, did you serve during the Vietnam Conflict (2/28/61-3/7/75) YesNo

Have you ever been convicted* for any violation(s) of law, including moving traffic violations. YesNo

If YES, please provide the following:

*Convictions include Virginia juvenile adjudications for Capital Murder, First and Second Degree Murder, Lynching, or Aggravated Malicious Wounding, if you were age fourteen (14) to eighteen (18) when charged.

When will you be available to start work? (No date is necessary if you are available as soon as you give two (2) weeks notice.)

CERTIFICATION -- Each Application Requires Current Date and Original Signature

I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of the Clerk of Norfolk Circuit Court. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent that you may contact references, former employers and educational institutions listed regarding this application. I further authorize the Clerk to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovermental organizations or systems on a need-to-know basis for good cause shown as determined by the Clerk or Chief Deputy.