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Roanoke Redevelopment and Housing Authority

An Equal Opportunity Employer

Application for Employment

Employees of RRHA and applicants for employment shall be afforded equal opportunity in all aspects of employment without regard to race, color, religion, national origin, citizenship, gender, age, disability, veteran status, or any other legally protected status in accordance with federal, state, and local statutes, regulations and ordinances.

Notice to Applicants

If you require an accommodation because of a physical or mental disability in order to participate in any phase of the application process, please make that fact known to the individual processing your application. If you are required to take any pre-employment screening tests, and you require an accommodation because of a physical or mental disability to enable you to take or successfully complete such a test, please make that fact known in advance to the test administrator. If an offer of employment is made and, because of a physical or mental disability, you will need an accommodation to perform any essential job function, please make that fact known to the individual processing your application.

Date:	02/06/2012
Position applied for:
Full Legal Name	Last:
	First:
	Middle:
Present Address:

City:
State/Zip:	State: Zip:
Phone:	Home Work
Email:
How did you learn about this position?
Are you related to another RRHA Employee? NoYes
If yes, provide name/relation:

Date available to start, if hired:	(mm/dd/yyyy)
Are you over 18 years of age?	NoYes
If hired, could you provide documentation certifying that you are authorized to work in the U.S.?	NoYes
Have you ever been convicted of any violation(s) of law (including moving traffic violations)?	NoYes
If yes, explain A yes answer will not necessarily be grounds for rejection. The relationship between the type, number and relatedness, among other factors, of convictions may be considered.
Answer the following question only if a requirement for the position for which you are applying.
Do you have a valid drivers license issued by the Commonwealth of Virginia?	NoYes
All employees are required to be bonded under RRHA's Fidelity Bond. Please answer the following questions concerning bonding.
Have you ever been bonded?	NoYes
Have you ever been refused bond or have bond coverage revoked?	NoYes
If yes, explain
Do you know of any reason you would be refused bond?	NoYes
If yes, explain

WORK RELATED SKILLS
Proficient in Software:
Typing speed	wpm
Office machines you can use
Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops and/or specialized achievements

Education
	Name/Address	No. Yrs Attended	Did you Graduate?	Degree
High School
College
Graduate Sch
Vocational Sch
Other Certificates and/or Licenses

Employment History Starting with present employer or most recent employer, please provide your complete employment history. Include any period of unemployment. If you have not previously worked for pay, you may list any applicable volunteer work you have done. NOTE All dates are mm/dd/yyyy MAY WE CONTACT YOUR PRESENT EMPLOYER? NoYes
Company Name		Dates	to
Address		Phone
Salary	(start-finish)	Position
Supervisor
Duties
Reason for Leaving

Company Name		Dates	to
Address		Phone
Salary	(start-finish)	Position
Supervisor
Duties
Reason for Leaving

Company Name		Dates	to
Address		Phone
Salary	(start-finish)	Position
Supervisor
Duties
Reason for Leaving
Resume Document/additional information (if needed): (Word or PDF format)

APPLICANT'S STATEMENT:

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 revocation of any offer of employment by RRHA or may cause forfeiture on my part of any employment relationship with RRHA.

I understand that all information on this application is subject to verification and I hereby authorize RRHA to make any investigation of my education, employment, criminal and motor vehicle history. I further authorize RRHA to rely upon and use, as it sees fit, any information received from such contacts.

I understand that neither this document nor any offer of employment from RRHA constitutes an employment contract. Furthermore, I understand and agree that the position for which I am applying will be for no definite term and that either I, or RRHA, will have the right to terminate the employment relationship at any time, with or without cause, and with or without written notice.

I understand that RRHA's selection and hiring policy prohibits the hiring of any applicant who uses illegal drugs. Furthermore, I understand and agree that as a part of the post-job offer employment process, I will be required to submit to pre-employment drug screening at RRHA's expense. In addition, I understand and agree that should I refuse to submit to a drug-screening test or fail such a test, RRHA's offer of employment will hereby be rescinded. My signature below represents my consent to RRHA's pre-employment screening procedures.

I hereby agree to conform to the rules and regulations of the Roanoke Redevelopment & Housing Authority.

SELECTING "YES" IMPLIES YOU HAVE SIGNED AND AGREED

YesNo

Consumer Report Disclosure

I hereby acknowledge and understand that the Roanoke Redevelopment and Housing Authority ("RRHA") may obtain reports, which may include a motor vehicle report, criminal background check, and/or employment and educational background verification, for employment purposes as a part of the pre-employment background investigation of my application for employment with RRHA and, if I am hired, thereafter at any time during my employment with RRHA.

By clicking "I agree" below, I am acknowledging that I have read, fully understand and voluntarily agree to the foregoing.

I AgreeI Disagree

Applicant Data Record

Applicants and employees are treated without regard to race, color, religion, sex, national origin, age, marital or veteran status, or disability, or any other legally protected status. Solely to help us comply with government record keeping, reporting and other legal requirements, we request that you please fill out the Applicant Data Record. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment. Your application will receive the same consideration whether or not you elect to complete this survey and this information will not be considered in evaluation of your application.

SUBMISSION OF THIS INFORMATION IS STRICTLY VOLUNTARY.

Position Applied For
Check one of the following:	MaleFemale
Check one of the following: White (not of Hispanic origin) - all persons having origins in any of the original peoples of Europe, North Africa or the Middle East Black/African American (not of Hispanic origin) - all persons having origins in any of the Black recial groups of Africa Hispanic - all persons of Mexican, Puerto Rican, Cuban, Central or South American, or Spanish culture or origin, regardless of race Asian or Pacific Islander - all persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, i.e. China, India, Japan, Korea, the Phillipine Islands, and Samoa American Indian or Alaskan Native - all persons having origins in any of the original peoples of North America, and who maintain cultural idetification through tribal affiliation or community recognition
Check if any of the following are applicable: Veteran of Uniformed Services Individual with a Disability
Date of birth (mm/dd/yyyy)
Referral Source Roanoke Times Roanoke Tribune Employment Flyer Agency (VEC/Other) Walk-in Friend Internal Posting RRHA Web Site Internet (monster.com, etc) Other
Section 3 requires that to the greatest extent possible, opportunities for training and employment be given to residents of our housing programs. In order to monitor RRHA’s compliance with Section 3 HUD regulations, please answer the following question(s):
Are you an RRHA resident?		Yes No
If Yes, please select one:		Section 8 Public Housing