CITY OF COVINGTON VIRGINIA 333 LOCUST STREET COVINGTON VA 24426 An equal opportunity employer. PERSONAL Name. (Last) Address (Street) Telephone. (Area Code)  EMPLOYMENT  APPLICATION  W.  (First) (City)  (Middle) (State)  (Zip Code)  Social Security Number. State Yes Yes No  Driver's License Number Have you ever been convicted of a felony int the last seven years? Are you a citizen of the United States? JOB NTERESISISKILLS Position(s) applied for.  Expiration Date.  No Explain Felony  Salary Desired  Have you applied for a position here before? Type ofe employment requested Date you could begin working  Yes Part Time  No Ifyes, when? Typing Speed (WPM)  Full Time  Temporary  Summer  Summarize any other special skills or qualifications  EDUCATION TYPE OF SCHOOL HIGHSCHOOL COLLEGE OR UNIVERSITY OTHER EDUCATION OTHER EDUCATION  NAME, LOCATION ANDI PHONE  COURSE OF STUDY  #OF GRADE MAXIMUM DEGREE, DIPLOMA, YEARS AVERAGE GRADE CERTIFICATEAND! RECEIVED HONORS    EMPLOYMENT HISTORY (LIST MOST RECENT FIRST)  1. Name of Employer. Address (Street) Supervisor and Title. Employed From Work Performed Reason for leaving. 2. Name of Employer. Address (Street) Supervisor and Title Employed From Work Performed Reason for leaving. 3. Name of Employer. Address (Street) Supervisor and Title. Employed From Work Performed Reason for leaving. REFERENCES  Phone (State)  (City)  (Zip Code)  Your Title Starting Salary  To  Ending Salary-  Phone (State)  (City)  (Zip Code)  Your Title Starting Salary  To  Ending Salary-  Phone (State)  (City)  (Zip Code)  Your Title Starting Salary  To  Ending Salary-  Name  Relationship  Home Phone  Daytime Phone  ACKNOWLEDGEMENT  Icertify that the answers given by me int this application are correct to the best ofr my knowledge. lunderstand that any falsifiçation oft this application, whether willingly or accidental, is grounds for disqualitication ofe employment consideration, or dismissal from employment ifl am hired. I authorize the companyt to contact any anda allo of the references Ihave listed above to obtain previous employment information or any other pertinent information that they may! have. Further, Ireleaset the above mentioned references from any and alll liability for any damages that mayr resultf from information collected by this company. Verification ofe eligibility to worki int the United States must be satisfied for an offert tol be made.  Applicant's Signature  Date