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Middlesex County Employment Application

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Steps

1. Personal Information(current) This section is complete This section is incomplete
2. Position Information This section is complete This section is incomplete
3. Education This section is complete This section is incomplete
4. Employment History This section is complete This section is incomplete
5. Military Service This section is complete This section is incomplete
6. References This section is complete This section is incomplete
7. Disclaimer & Signature This section is complete This section is incomplete

Personal Information

First Name*
Last Name*
Address1*
Address2
City*
State*
Zip*
Phone Number*
Email Address*
Are you eligible to work in the United States?*
1. Yes
1. No
Upload Your Resume
Continue

Position Information

Which position are you applying for?*
Type of employment desired*
1. Full Time
1. Part Time
1. Internship
Salary desired*
Hours of work (per week) desired*
How did you hear about the position?*
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Education

High School
Address
College
Address
Degree
Other
Address
Degree
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Employment History

(From Most Recent)
Company
Position
Supervisor
Phone Number
May we contact your previous supervisor for a reference?
1. Yes
1. No
Address
Responsibilities
Employed From - To (Date)
Salary
Company
Position
Supervisor
Phone Number
May we contact your previous supervisor for a reference?
1. Yes
1. No
Address
Responsibilities
Employed From - To (Date)
Salary
Company
Position
Supervisor
Phone Number
May we contact your previous supervisor for a reference?
1. Yes
1. No
Address
Responsibilities
Employed From - To (Date)
Salary
Continue |Go Back

Military Service

Branch of Service:
From:
From:
From:
To:
To:
To:
Rank at Discharge
Are You Currently in the Armed Forces?
1. Yes
1. No
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References

Please list three professional references.
Full Name*
Relationship*
Company*
Phone Number*
Full Name*
Relationship*
Company*
Phone Number*
Full Name*
Relationship*
Company*
Phone Number*
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Disclaimer & Signature

Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature

Leave This Blank:

1. Receive an email copy of this form.
Email address

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Middlesex County
P.O. Box 428
Saluda, VA, 23149

Phone: 804-758-4330

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