APPLICATION OF EMPLOYMENT
Selected applicants for employment are required to undergo a background, drug and alcohol screening. Some jobs may require a credit check and a driving record check. Pulaski County is an Equal Opportunity Employer and does not discriminate based on race, color, religion, sex, sexual orientation, gender identity/transgender status, marital status, political affiliation, age,
national origin, genetic makeup, veteran status or disability, which if needing accommodation, may be reasonably accommodated and commit to following federal, state and local anti-discrimination laws.
*Due to the volume of applications received, only those selected for interviews will be contacted.
*Applications should be submitted to: Department of Human Resources, 143 Third Street, NW, Suite 1, Pulaski, VA 24301, via fax ... or via email at ....
APPLICANT INFORMATION
Name: _____________________________________
Phone: _________________________
Address: _________________________________________________________________________
Email: _______________________________
Legal Guardian Email: _________________________
If you are an applicant under the age of 18 please provide a legal guardians email address
Do you possess a CDL?
Yes
No
What class? _____________________________
POSITION YOU ARE APPLYING FOR
Title: _____________________________________
Available start date?
____________
EDUCATION
GED
Bachelor's Degree
High School Diploma
Master's Degree
Associate's Degree
Doctorate
Which College or University? ____________________________________
Field of study? ________________________________________________
REFERENCES
Name
Title
Company
Phone/email
EMPLOYMENT HISTORY
Employer
City & State Position
Dates of
of Business
Employment
Please attach a resume that includes a full description of all previous employment and job duties.
Please list the reason for leaving employment:
Have you ever been forced to resign or terminated from a position? Yes No
AUTHORIZATION TO CONTACT PREVIOUS EMPLOYER
May we contact your previous employer to discuss position held, duties performed and reason
for leaving?
Yes
No
SIGNATURE/DISCLAIMER
By signing below, I hereby certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that any false or misleading information, whether intentional or unintentional, failure to answer questions or leave blank responses, regardless of time of discovery, on my application or during my interview may result in termination of my employment. I also understand that Pulaski County is required to provide information regarding my employment to Federal or State agencies for use in employment investigations and inquiries. I further understand that the information included with this application is subject to verification and consent to Pulaski County contacting my references and former employer in consideration of my employment.
Applicant Signature: ______________________________________ Date: _____________________
--------------------------------------------------------------------------------------------------------------------------
Pulaski County is an At-Will employer. Unless otherwise stated in a written agreement signed by the County Administrator. This means that either the County or the employee may terminate employment at any time for any reason, with or without notice.
Equal Employment Opportunity Self-Identification Applicant
Survey
Applicant Name: __________________________________________________
Date: ______________
Position Applied For: ______________________________________________
Date of Birth: ______________
Survey of Sex, Ethnic Group and Race
Our organization is an equal opportunity employer and government contractor. It has been and shall continue to be both the official policy and the commitment of the Company, including all its divisions to further equal employment opportunities in hiring or employment. Our organization is committed to the employment and advancement of minorities, females, individuals with disabilities, and veterans. No question on this form is intended to secure information to be used for such discrimination. If you fall into one of these protected classifications, we invite you to identify to yourself and receive coverage under our company's Affirmative Action Plan.
Completion of this form is voluntary and in no way affects the decision regarding your employment opportunity. Our organization is required by federal regulations to report information as requested below. The information provided will be held in the strictest confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with the Acts. You may inform us of your status related to the following data or your change in status at this time and/or any time in the future.
*Note: EEO-1 Component 1 data collection provides only binary options (i.e., male or female).
Select the categories that apply. Definitions below.
Sex:
____ Male
____ Female
Ethnic Group:
____ Hispanic or Latino
____ Not Hispanic or Latino
____ Asian
____ Native Hawaiian or Other Pacific Islander
____ Black or African American
____ White
Race:
____ American Indian or Alaska Native
____ Two or More races
Definitions - Race / Ethnic Groups
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
Applicant Survey
Survey of Protected Veteran Status
This employer is a government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended (Section 4212), which requires government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. Our affirmative action policy prohibits discrimination and requires us to take affirmative action to employ and advance in employment qualified protected veterans at all levels of employment. The below invitation is made pursuant to this policy.
Disclosure of this information is voluntary and refusing to provide it will not subject you to any adverse treatment. The information will be used only in ways that are consistent with Section 4212. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
Protected veterans may have additional rights under USERRAthe Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.
INVITATION TO SELF-IDENTIFY
PLEASE ANSWER THE FOLLOWING QUESTIONS
Do you identify as one (or more) of the following protected veteran categories? Categories and definitions below. Please check the appropriate box below this section. NOTE: You do not have to indicate which specific category applies.
Disabled Veteran: (i) a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veteran Affairs; or (ii) a person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran: any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
Armed Forces Service Medal Veteran: a veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in a United States military operation for which an Armed Forces medal was awarded pursuant to Executive Order 12985.
Active Duty Wartime or Campaign Badge Veteran: a veteran who served on active duty in the U.S. military, ground, naval, or air service either during a period of war as defined below or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
Period of war is defined for these purposes by the Department of Labor as:
June 27, 1950 to January 31, 1955
(Korean conflict)
February 28, 1961 to May 7, 1975
(for veterans serving in the Republic of Vietnam)
August 5, 1964 to May 7, 1975 (for all other veterans who served during the Vietnam conflict)
August
2, 1990 to the present (Gulf War)
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.
I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE.
YOUR SPOUSE IS A VERTERAN.
I AM NOT A PROTECTED VETERAN.
I DECLINE TO ANSWER.
Selective Service Registration
Federal law requires most male applicants born after December 31, 1959, to be registered with the Selective Service System to be eligible for employment.
Are you in compliance with Selective Service registration requirements?
Yes
No
Not Applicable
If No, please provide an explanation:
Applicant Name: __________________________________________________
Date: ______________
Voluntary Self-Identification of Disability
Form CC-305 OMB Control Number 1250-0005 Page 1 of 1 Expires 04/30/2026
Name:
Date:
Employee ID:
(if applicable)
Why are you being asked to complete this form?
We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.
Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
How do you know if you have a disability?
A disability is a condition that substantially limits one or more of your major life activities. If you have or have ever had such a condition, you are a person with a disability.
Selected applicants for employment are required to undergo a background, drug and alcohol screening. Some jobs may require a credit check and a driving record check. Pulaski County is an Equal Opportunity Employer and does not discriminate based on race, color, religion, sex, sexual orientation, gender identity/transgender status, marital status, political affiliation, age,
national origin, genetic makeup, veteran status or disability, which if needing accommodation, may be reasonably accommodated and commit to following federal, state and local anti-discrimination laws.
*Due to the volume of applications received, only those selected for interviews will be contacted.
*Applications should be submitted to: Department of Human Resources, 143 Third Street, NW, Suite 1, Pulaski, VA 24301, via fax ... or via email at ....
APPLICANT INFORMATION
Name: _____________________________________
Phone: _________________________
Address: _________________________________________________________________________
Email: _______________________________
Legal Guardian Email: _________________________
If you are an applicant under the age of 18 please provide a legal guardians email address
Do you possess a CDL?
Yes
No
What class? _____________________________
POSITION YOU ARE APPLYING FOR
Title: _____________________________________
Available start date?
____________
EDUCATION
GED
Bachelor's Degree
High School Diploma
Master's Degree
Associate's Degree
Doctorate
Which College or University? ____________________________________
Field of study? ________________________________________________
REFERENCES
Name
Title
Company
Phone/email
EMPLOYMENT HISTORY
Employer
City & State Position
Dates of
of Business
Employment
Please attach a resume that includes a full description of all previous employment and job duties.
Please list the reason for leaving employment:
Have you ever been forced to resign or terminated from a position? Yes No
AUTHORIZATION TO CONTACT PREVIOUS EMPLOYER
May we contact your previous employer to discuss position held, duties performed and reason
for leaving?
Yes
No
SIGNATURE/DISCLAIMER
By signing below, I hereby certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that any false or misleading information, whether intentional or unintentional, failure to answer questions or leave blank responses, regardless of time of discovery, on my application or during my interview may result in termination of my employment. I also understand that Pulaski County is required to provide information regarding my employment to Federal or State agencies for use in employment investigations and inquiries. I further understand that the information included with this application is subject to verification and consent to Pulaski County contacting my references and former employer in consideration of my employment.
Applicant Signature: ______________________________________ Date: _____________________
--------------------------------------------------------------------------------------------------------------------------
Pulaski County is an At-Will employer. Unless otherwise stated in a written agreement signed by the County Administrator. This means that either the County or the employee may terminate employment at any time for any reason, with or without notice.
Equal Employment Opportunity Self-Identification Applicant
Survey
Applicant Name: __________________________________________________
Date: ______________
Position Applied For: ______________________________________________
Date of Birth: ______________
Survey of Sex, Ethnic Group and Race
Our organization is an equal opportunity employer and government contractor. It has been and shall continue to be both the official policy and the commitment of the Company, including all its divisions to further equal employment opportunities in hiring or employment. Our organization is committed to the employment and advancement of minorities, females, individuals with disabilities, and veterans. No question on this form is intended to secure information to be used for such discrimination. If you fall into one of these protected classifications, we invite you to identify to yourself and receive coverage under our company's Affirmative Action Plan.
Completion of this form is voluntary and in no way affects the decision regarding your employment opportunity. Our organization is required by federal regulations to report information as requested below. The information provided will be held in the strictest confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with the Acts. You may inform us of your status related to the following data or your change in status at this time and/or any time in the future.
*Note: EEO-1 Component 1 data collection provides only binary options (i.e., male or female).
Select the categories that apply. Definitions below.
Sex:
____ Male
____ Female
Ethnic Group:
____ Hispanic or Latino
____ Not Hispanic or Latino
____ Asian
____ Native Hawaiian or Other Pacific Islander
____ Black or African American
____ White
Race:
____ American Indian or Alaska Native
____ Two or More races
Definitions - Race / Ethnic Groups
Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Black or African American (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian or Alaska Native (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.
Applicant Survey
Survey of Protected Veteran Status
This employer is a government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended (Section 4212), which requires government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. Our affirmative action policy prohibits discrimination and requires us to take affirmative action to employ and advance in employment qualified protected veterans at all levels of employment. The below invitation is made pursuant to this policy.
Disclosure of this information is voluntary and refusing to provide it will not subject you to any adverse treatment. The information will be used only in ways that are consistent with Section 4212. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.
Protected veterans may have additional rights under USERRAthe Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.
INVITATION TO SELF-IDENTIFY
PLEASE ANSWER THE FOLLOWING QUESTIONS
Do you identify as one (or more) of the following protected veteran categories? Categories and definitions below. Please check the appropriate box below this section. NOTE: You do not have to indicate which specific category applies.
Disabled Veteran: (i) a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veteran Affairs; or (ii) a person who was discharged or released from active duty because of a service-connected disability.
Recently Separated Veteran: any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
Armed Forces Service Medal Veteran: a veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in a United States military operation for which an Armed Forces medal was awarded pursuant to Executive Order 12985.
Active Duty Wartime or Campaign Badge Veteran: a veteran who served on active duty in the U.S. military, ground, naval, or air service either during a period of war as defined below or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
Period of war is defined for these purposes by the Department of Labor as:
June 27, 1950 to January 31, 1955
(Korean conflict)
February 28, 1961 to May 7, 1975
(for veterans serving in the Republic of Vietnam)
August 5, 1964 to May 7, 1975 (for all other veterans who served during the Vietnam conflict)
August
2, 1990 to the present (Gulf War)
If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below.
I IDENTIFY AS ONE OR MORE OF THE CLASSIFICATIONS OF PROTECTED VETERAN LISTED ABOVE.
YOUR SPOUSE IS A VERTERAN.
I AM NOT A PROTECTED VETERAN.
I DECLINE TO ANSWER.
Selective Service Registration
Federal law requires most male applicants born after December 31, 1959, to be registered with the Selective Service System to be eligible for employment.
Are you in compliance with Selective Service registration requirements?
Yes
No
Not Applicable
If No, please provide an explanation:
Applicant Name: __________________________________________________
Date: ______________
Voluntary Self-Identification of Disability
Form CC-305 OMB Control Number 1250-0005 Page 1 of 1 Expires 04/30/2026
Name:
Date:
Employee ID:
(if applicable)
Why are you being asked to complete this form?
We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.
Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.
How do you know if you have a disability?
A disability is a condition that substantially limits one or more of your major life activities. If you have or have ever had such a condition, you are a person with a disability.
Job ID: 520836808
Originally Posted on: 5/12/2026
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