Patrick Henry Boys and Girls Plantation, Inc

Patrick Henry Boys and Girls Plantation, Inc

AdministrationPO Box 1398

434-376-2006 phoneBrookneal VA 24528

434-376-3003 fax


Please Print or Type Date


Full Name Previous Names

Present Address

Telephone Number Is this the best number to reach you? Yes No

If no, please provide number at which we should reach you

Best time to call E-mail address


Position Desired Date you could start

Friends or relatives in our employ

Are you a veteran of the United States Armed Forces?

What caused you to contact us?


Name & Location / Last Year Completed / Dates of Attendance / Graduate? / Degree/Area
High School / 1 2 3 4
/ Yes
College / 1 2 3 4
/ Yes
Other / 1 2 3 4
/ Yes


List present or last position first and continue in reverse order, particularly noting any that you feel will help you in work here.

Dates / Employer Name & Address / Salary / Position & Duties / Reason for Leaving

May we contact your present employer? If no, why?

Are you authorized to work in the U.S.?

Do you hold any professional licenses or certifications?

Have you ever been discharged or requested to resign from a position? (If yes, explain below or on the back of this form.)

REFERENCESReferences other than employers or relatives whom you have known for five or more years:

Name / Address / Phone / Years Known


Driver's License # State Year

Class / Endorsements

Driving Violations (Last five years; provide offenses and dates)

Have you ever been convicted of any criminal act? If so, state offense and dates:

Are there any criminal charges or proceedings pending against you? (If yes, explain below or on the back of this form.)

Have you ever been convicted, or do you have pending charges against you, of child abuse or neglect?

Why would you like to work at Patrick Henry Family Services?

Please write a brief outline of your Christian testimony. Use the back or attach additional pages, if necessary.

Please describe briefly your goals for the future.

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed.

The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

This application is current for 60 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to fill out a new application.

I understand that just as I am free to resign at any time, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.

My signature below authorizes Patrick Henry Family Services to conduct a background investigation and authorizes release of information in connection with my application for employment. This investigation may include such information as criminal or civil convictions, driving records, previous employers, and educational institutions, personal references, professional references, and other appropriate sources. I waive my right of access to any such information, and without limitation hereby release the Patrick Henry Family Services and the reference source from any liability in connection with its release or use. This release includes the sources cited above and specific examples as follows: local Sheriffs or Deputies, any law enforcement personnel, information from the Central Criminal Records Exchange of either data on all criminal convictions or certification that no data on criminal convictions are maintained, information from the Virginia or other State Department or Agency of Social Services referring to Child Protective Services, and any Locality to which they may refer for release of information pertaining to any findings of child abuse or neglect investigation involving me whether or not there was any finding of abuse made.


Signature of Applicant Date

(Rev. 6/5/2014)

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