Virginia Peninsulas
Public Service Authority

Application for Employment

Virginia Peninsulas Public Service Authority
475 McLaws Circle, Suite 3B, Williamsburg, VA 23185-5676
(757) 259-9850
VPPSA is an Equal Opportunity Employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disablity or handicap, or veteran status.
Instructions: Please read before completing this form.
  • Type or print clearly in dark ink and do not abbreviate if possible
  • Each item on the form must be completed
  • If an item does not apply, write “Not Applicable” or “N/A” in the space provided
  • List the position for which you want to be considered in the appropriate box. You will only be considered for a position that is open at the time you apply
  • Before signing this form, carefully read the Privacy Act Notice for Employment Forms below the form.
  • Applications must be signed and dated by the applicant on the last page of the form

General Information

If you currently work for VPPSA, or have in the past, complete the box below

If any members of your family presently work for VPPSA, complete the box below:
If you have ever, as an adult, been convicted of a misdemeanor or felony other than a minor traffic violation, give details in the space below. Include the date of conviction, and the nature or disposition of the offense. (A conviction will not necessarily disqualify you for employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.)
All new employees will be required to complete a Form I-9 and provide documents establishing their identity and eligibility to work in the Unites States

Education, Certificates, and Special Training

Please list the Colleges and/or Universities you have attended, including the City, State, Zip Code if known, and other information requested.

(If you expect to graduate within 9 months, give month and year you expect to receive your degree.)

Other schools or training (for example, trade, vocational, armed forces, or business. For each course named, please provide the date and training organization.

List special qualifications and skills (licenses, patents, inventions, publications, etc.)

Experience

Start with your present position and work back. Account for periods of unemployment. You may include unpaid experience or volunteer work if you feel that it represents qualifying experience for the position for which you are applying.

Position 1

(Manufacturing, Account, Insurance, Etc.)

Position 2

(Manufacturing, Account, Insurance, Etc.)

Position 3

(Manufacturing, Account, Insurance, Etc.)

Position 4

(Manufacturing, Account, Insurance, Etc.)

Privacy Policy

The policy of the Virginia Peninsulas Public Service Authority is to collect, maintain, use and disseminate only the personal information required by law to accomplish a proper purpose.

Purpose, Use, Access, and Dissemination

Information furnished will be used primarily by VPPSA to determine qualifications for employment, eligibility for transfer, reinstatement, promotion, and/or demotion. All or part of this information may be furnished as indicated below:

1. Representatives from VPPSA, if required to determine employment suitability.
2. Federal, state, and local agencies in which you have an interest as a potential employee.
3. Federal, state, and local agencies to create personnel files following your employment withVPPSA.
4. Representatives of federal, state, and local agencies engaged in investigating violations of the law.
5. Individuals or agencies requesting statistical data exclusive or personal information.
6. Requesting agencies possessing your voluntary release of information and assuming confidential
protection of information released.

Effects of Nondisclosure

It is in your best interest to answer all questions on the Application for Employment. Your failure to complete the form may jeopardize your opportunity for employment. Completion of the EEO Applicant Information form which follows is voluntary, and cannot be used to jeopardize an opportunity for employment.

Certification / Agreement

I have read and understand the above Privacy Act Notification for Employment Forms. I hereby certify that this application is a complete record and that all entries and all attachments are true and accurate to the best of my knowledge. I understand that false or incomplete statements herein supplied are grounds for disqualification from employment. I authorize VPPSA to conduct a thorough background investigation, except as it pertains to race, origin, sex, age, or other non-job-related criteria, to be used relative to my employment with VPPSA. I authorize my former employers and any other persons or organizations to provide any information they have about me and I release all concerned from any liabilities in connection therewith. If permanent employment is offered, I understand that I may be required to pass an examination given at VPPSA’s expense, and that my employment may be dependent upon successfully passing that examination.