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Middleburg Police Employment Application

3. 

5. First Name*

6. Last Name*

8. Address1*

10. Address2

12. City*

13. State*

14. Zip*

16. Phone Number*

17. Email Address*

19. Drivers license number*

    List your drivers license number and the state of issue

21. Virginia DCJS certification*

    List the academy and the expiration date

25. Have you ever been convicted of a violation of the law other than a minor traffic violation?*

    1. Yes

    1. No

27. Details and specific charge(s)*

    List the charges and the dates of conviction. Offer an explanation if you desire.

29. Are you eligible to work in the United States?*

    1. Yes

    1. No

31. Which position are you applying for?*

33. How did you hear about the position?*

35. High School

36. Address

38. College

39. Address

40. Degree

42. Other

43. Address

44. Degree

46. (From Most Recent)

48. Company

49. Position

51. Supervisor

52. Phone Number

54. Address

56. Responsibilities and reason left

58. Employed From - To (Date)

59. Salary

63. Company

64. Position

66. Supervisor

67. Phone Number

69. Address

71. Responsibilities and reason left

73. Employed From - To (Date)

74. Salary

78. Company

79. Position

81. Supervisor

82. Phone Number

84. Address

86. Responsibilities and reason left

88. Employed From - To (Date)

89. Salary

91. Have you ever used illegal drugs?*

    1. Yes
    2. No

    Illegal drugs are defined as "any prescription drug not prescribed to you, any drug whose production or use is prohibited or controlled via prescription."

92. Drug use explanation*

    List types of drugs used, approximate dates/years, and last date/year used. List N/A if never used an illegal drug.

94. Please list three professional references.

96. Full Name*

97. Relationship*

99. Company*

100. Phone Number*

104. Full Name*

105. Relationship*

107. Company*

108. Phone Number*

112. Full Name*

113. Relationship*

115. Company*

116. Phone Number*

118. I certify that my answers are true and complete to the best of my knowledge and that intentional misrepresentations or omissions may be cause for the rejection of my application and that if hired I may be released from employment. <Br><br>I understand that the company may require me to successfully complete a pre-employment drug and alcohol test and a background check as a condition of employment and that continued employment may be based on the successful completion of similar tests. <br><br>Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box and clicking submit button I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information.

     I certify that my answers are true and complete to the best of my knowledge and that intentional misrepresentations or omissions may be cause for the rejection of my application and that if hired I may be released from employment.
     
     I understand that the company may require me to successfully complete a pre-employment drug and alcohol test and a background check as a condition of employment and that continued employment may be based on the successful completion of similar tests.
     
     Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box and clicking submit button I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information.

120. Applicant Signature*

Leave This Blank:


122. 1. Receive an email copy of this form.
123. Email address

     This field is not part of the form submission.

124. Submit

* indicates a required field