First Name*
Middle Name
Last Name*
Cell/Home Phone
Work Phone
Email*
Email Confirmation*
Please list below your current address and your two other most recent previous addresses within five years.
Current Street*
Current City*
Current State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Current Zip*
Current Address Since*
Previous Street Address 1
Previous City Address 1
Previous State 1 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Previous Zip 1
Moved to Previous Address 1 on:
Previous Street Address 2
Previous City Address 2
Previous State 2 Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Previous Zip 2
Moved to Previous Address 2 on:
High School Attended*
Diploma or Degree Earned*
High School City*
High School County*
High School State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Undergraduate College Attended
Undergraduate Areas of Study
Undergraduate Degree/Certificate/Diploma Earned
Undergraduate College City
Undergraduate College State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Graduate School Attended
Graduate Areas of Study
Graduate Degree/Certificate/Diploma Earned
Graduate School City
Graduate College State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Trade/Business or Other School Attended
Areas of Study
Degree/Certificate/Diploma Earned
Trade/Business/Other School City
Trade/Business/Other School State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
How did you learn about us? Desired Position*
Date You Can Start Work*
Desired Salary
Would you consider part time without benefits? Please answer all of the following 9 questions. When necessary, note question number and use this field to provide any additional explanations.
1.) Are you at least 18 years of age and legally eligible for work in the United States?* 2.) Will you work overtime when necessary?* 3.) Have you received a description of the job or been made aware of the essential functions of the job you are applying for?* 4.) Do you understand the job requirements and can you perform the essential functions of the job applied for?* 5.) Do you need any accommodations to perform the job applied for?* 6.) Are you on layoff and subject to recall?* 7.) Were you previously employed with us?* 8.) Do you have any relatives working for us?* 9.) May we contact your present employer?*
Please list below your last three employers beginning with the most recent.
1a. Employer*
1b. Employer Phone*
1c. Employer Address*
1d. Employer City*
1e. Employer State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
1f. Employer Zip*
1g. Position Held*
1h. Position Started*
1i. Position Held Until
1j. Current or Ending Pay Rate*
1k. Position Duties*
1l. Supervisor*
1m. Reason for Leaving
2. Second Most Recent Employer
2a. Employer*
2b. Employer Phone*
2c. Employer Address*
2d. Employer City*
2e. Employer State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
2f. Employer Zip*
2g. Position Held*
2h. Position Started*
2i. Position Held Until*
2j. Ending Pay Rate*
2k. Duties*
2l. Supervisor*
2m. Reason for Leaving*
3. Third Most Recent Employer
3a. Employer*
3b. Employer Phone*
3c. Employer Address*
3d. Employer City*
3e. Employer State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
3f. Employer Zip*
3g. Position Held*
3h. Position Started*
3i. Position Held Until*
3j. Ending Pay Rate*
3k. Duties*
3l. Supervisor*
3m. Reason for Leaving*
Additional Employment History (if needed)
Use this area to add more employment history if the last 3 positions held represent less than 5 years.
Were you in the U.S. Armed Forces? -Select One- Yes No
If yes, what branch?
Start Date of Duty
End Date of Duty
Rank at Discharge
List duties in the service including special training.
Please use this space to list any special skills you may have that relate to the position applied for.
Check boxes indicating kind of work in which you have experience with or job fields you have worked in (Check all that apply): Please list any professional licenses, designations, certifications, etc. that may relate to the position applied for. Include date granted, name of organization, and any other relevant information.
Applicant's Certification Agreement/Release of Information
1. In making this application for employment, I do hereby authorize a review of and full disclosure of all records concerning myself to any duly authorized agent of the Housing Authority of Richmond, whether the said records are of a public, private, or confidential in nature through a background check. I also certify that any person(s) who may furnish such information condemning me shall not be held accountable for giving this information, and I do hereby release said person(s) from any and all liability that may be incurred as a result of furnishing such information. A photocopy of this statement will be valid as an original thereof, even though the said photocopy authorizes past employers, all references, and other persons to answer all questions concerning my ability, character, reputation, and previous employment records. I release all such persons from any liability that might result from providing this information.
2. I certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application (or on any required documents) will be cause for denial of employment or immediate termination of employment regardless of when or how discovered.
3. I authorize the investigation of all statements contained in this application and release from all liability any persons or employers supplying such information, and I also release the company from all liability that might result from making the investigation.
4. If I am offered and accept a position, I agree to conform to all existing and future Housing Authority rules and regulations and I understand that the Housing Authority reserves the right to change wages, hours, and working conditions as deemed necessary. I also understand that, if hired, my employment will be at will, meaning that either party can end the employment relationship at any time and for any or no reason.
5. As a condition of employment, I hereby agree to provide my driving record.
6. I also will provide a criminal background history which may be investigated and authorize the release of the results to the Housing Authority and/or authorize a criminal background check be conducted.
7. As a condition of employment, I hereby agree to submit to a drug screen test; and that my employment is contingent upon passing a substance abuse screening.
8. I also understand that my employment is subject to an initial orientation period and verification that age and citizenship/visa status meet legal requirements.
9. I have read and reviewed the information provided in this application and the above statements. By signing this application for employment, I certify that I understand all parts of it and have answered all questions completely and fully.
10. Failure to sign this consent discontinues the employment process.
Applicant Signature (by typing your name, you are signing this form)*
Signature Date*
