Employment Application Step 1 of 10 - Personal Information 10% Name(Required)Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Date of Birth MM slash DD slash YYYY Date Available MM slash DD slash YYYY Position Applied ForAre you a US citizen? Yes No Have you worked for PRJA in the past? Yes No Provide previous employment detailsDo you have any relatives presently employed at PRJA? Yes No Provide name and relationship High SchoolHigh School NameHigh School LocationAttended FromAttended ThroughDid you graduate? Yes No GED CollegeCollege NameCollege LocationAttended FromAttended ThroughDegreeOtherCollege NameCollege LocationAttended FromAttended ThroughDegree Company 1 InfoCompany NamePhoneAddressSupervisorJob TitleStarting SalaryEnding SalaryResponsibilitiesFromToReason for LeavingMay we contact your previous employer for a reference? Yes No Company 2 InfoCompany NamePhoneAddressSupervisorJob TitleStarting SalaryEnding SalaryResponsibilitiesFromToReason for LeavingMay we contact your previous employer for a reference? Yes No Company 3 InfoCompany NamePhoneAddressSupervisorJob TitleStarting SalaryEnding SalaryResponsibilitiesFromToReason for LeavingMay we contact your previous employer for a reference? Yes No Have you ever served in any branch of the Armed Forces of the United States? Yes No OrganizationDate EnteredDate of SeparationType of DischargeAre you currently a member of the National Guard or any military reserve? Yes No Describe your obligation Do you have a valid driver’s license? Yes No Has your license ever been suspended? Yes No Has your license ever been revoked? Yes No State of IssueLicense NumberPlease provide details, including court locations and dates.facts so that a decision can be made.Have you ever been convicted, arrested, or charged with a felony, misdemeanor, or moving traffic violation; whether found guilty or not? Yes No A conviction does not necessarily mean that you cannot become employed. Please give all the facts so that a decision can be made.OffenseDate of OffenseLocation of Court ProceedingFine or SentenceHave you ever been discharged from any position because of misconduct or unsatisfactory performance? Yes No DetailsHave you ever held positions that required supervisory ability? Yes No DetailsDo you have a reliable means of transportation to and from work? Yes No Do you speak any foreign languages? Yes No What language and describe your level of proficiencyDo you have automobile liability insurance, assigned risk, or certification of compliance with the Uninsured Motor Vehicle Act? Yes No Describe any extended absences from work. Be sure to explain any gaps in employment history as wellHave you ever used illegal drugs in any form? Yes No DetailsHave you ever had any affiliations with gangs? Yes No DetailsAre you available to work day, evening and/or nights shifts 7 days per week? Yes No Have you ever engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution? Yes No Have you ever been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied force, or coercion, if the victim did not consent or was unable to consent or refuse? Yes No Have you ever been civilly or administratively adjudicated to have engaged in sexual activity in the community facilitated by force, overt or implied force, or coercion, if the victim did not consent or was unable to consent or refuse? Yes No ReferencesNameRelationshipCompanyPhoneAddress Add Remove I certify that this application is a complete record and that all entries and attachments are true and accurate to the best of my knowledge. I understand that falsification, misrepresentation or omission of facts will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered. I understand that all information on this application is subject to verification and I consent to criminal history, prior employment, and driving record background checks. I understand that I may have to pass a physical examination and drug screening as a condition of my employment. Printed NameDate MM slash DD slash YYYY Signature(Required) Voluntary EEO DataFederal law prohibits the unlawful discrimination on the basis of race, color, sex, age, national origin, religion, or disability. PRJA complies with these federal regulations. This information will not be used for hiring purposes and will be stored separate from the application. Responses will be used for statistical data only. Completion of this information is voluntary.Gender I choose not to provide this information Male Female Race I choose not to provide this information White (Not Hispanic or Latino) Hispanic or Latino American Indian or Alaskan Native Two or more races (Not Hispanic or Latino) Black or African American Asian Native Hawaiian or Pacific Islander How did you find out about this job opportunity? I choose not to provide this information PRJA Website Job Fair Employee Referral Other Driving Record Release AuthorizationAs a standard procedure required by Piedmont Regional Jail Authority, all individuals who are seeking employment with Piedmont Regional Jail Authority, must process and show proof of a valid driver’s license and an acceptable driving record. In order to obtain your motor vehicle record information, we request that you complete and sign this Authorization for Release of Information Form. This information is considered confidential and will be treated as such. The information obtained within your motor vehicle record is limited to our insurance agent(s) and will not be shared with other entities.Driver's NameDate of Birth MM slash DD slash YYYY State of License IssuedAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDriver's License NumberHome AddressDaytime PhoneCellI certify that the information presented above is true and correct to the best of my knowledge. I authorize Piedmont Regional Jail Authority and its agent(s) to obtain my Motor Vehicle / Driving Record information for the purpose of determining eligibility for employment. This information shall remain on file and shall serve as ongoing authorization for any future motor vehicle record screens. Signature(Required) Criminal Background Check AuthorizationI have applied for a position with Piedmont Regional Jail Authority. This designation permits the agency to conduct a fingerprint-based and NCIC criminal history check. Therefore, I hereby authorize any investigator or duly accredited representative of the Piedmont Regional Jail Authority bearing this release, or a copy thereof, to obtain any information from law enforcement/criminal justice agencies and report the results of such search to the designated representative of the agency named above. I direct that such information be released upon request to the bearer of this form. I understand that the information released is for official use by Piedmont Regional Jail Authority. I submit to fingerprinting and understand that my fingerprints will be sent to the Virginia State Police for a criminal history check. I hereby release any individual, including records custodians, from any and all liability for damages of whatever kind or nature that may at any time result to me on account of compliance, or any attempt to comply, with this authorization. Should there be any questions as to the validity of this release, you may contact me as indicated below. I understand that any and all information collected pursuant to this background check may be used in assessing my suitability for the position for which I have applied. The information will not be shared with parties outside of the agency where the position is located. I further understand that I may challenge the results of the background investigation conducted by the Virginia State Police or the Federal Bureau of Investigation and may request information needed to make such a challenge from Piedmont Regional Jail Authority.Signature(Required)Full NameOther names currently or previously usedCurrent addressPhoneCAPTCHA
