Fillable Printable Application for Examination Instructions - West Virginia
Fillable Printable Application for Examination Instructions - West Virginia
Application for Examination Instructions - West Virginia
West Virginia Division of Personnel
APPLICATION FOR EXAMINATION
INSTRUCTIONS
This is a special Microsoft Word 97 version of the Division of Personnel Application for
Examination form. The form is equivalent to the standard Division of Personnel green Application
form. An Employment History Supplement sheet is available if you need additional space. These
forms should print satisfactorily on most printers; however, make sure all the checked (X) boxes print
properly. In most case, you can tab from field to field. We recommend that you print a blank form to
use as a draft. Check your responses very carefully. These two instruction pages
are not part of the
application and should not be submitted with the completed form. If you have any questions, please
call our office.
General Information.
Information about testing, announced job titles, testing locations, and the employment process are
available on our web site at: www.state.wv.us/admin/personel . The web site also has a map of WV
counties to assist you in determining your availability area. You may also obtain information by
calling our office and speaking with a counselor. If you are planning to take a written examination,
TAKE your completed application to the examination center when reporting for testing. Do not mail
an application for a written examination to our office. Applications for jobs which do not require a
written test should be mailed or delivered to the address shown on the form. A photocopy of the
application with signature and current date is acceptable. A resume cannot be substituted for the
application. Resumes and other supporting documents may be enclosed with the completed application.
Availability for Interview and Appointment.
(Very Important)
In order to process your application, we must know the counties in which you are willing to
interview and accept employment. Space has been provided on the Application for you to indicate from
1 to a maximum of10 counties in which you are definitely
available for work. DO NOT MARK
MORE THAN 10 COUNTIES. Do not mark a county that would require you to change residences, if
you are not willing to re-locate. If you mark more than 10 your application may be rejected. Mark
“All counties
” ONLY if you are certain you will accept work in any county in the State. A printable
map is available on our web site showing the location of all counties.
Documentation of Training and Experience.
Proof of degree(s), major fields of study, specific course work, license(s), vocational or other
required training must be attached to the completed application. An applicant's test may be scored but
will not be considered for employment until the required documents are received. Copies of documents
will be accepted providing all information is clearly shown.
All employment listed on the Application is subject to verification. Be sure to include all relevant
experience (including military experience) in the Employment History section. You MUST indicate
"hours per week" for any part-time work. All employment dates MUST be complete and accurate. If
you need additional space for your employment history, download one or more copies of the
Employment History Supplemental Sheet from our Web site.
Equal Employment Opportunity.
The WV Division of Personnel assures all applicants of equal opportunity when applying for
employment. No applicant will be discriminated against based on race, sex, age, religion, national
origin, political affiliation, disability, or any other non-job related factors. Further, it is the policy of the
Division of Personnel to ensure that only qualified individuals are certified for employment. We
provide all reasonable accommodations for persons with disabilities. Call our office for assistance
and information.
Continue reading on the next page.
West Virginia Division of Personnel
APPLICATION FOR EXAMINATION
INSTRUCTIONS - CONTINUED
Military Service and Veterans Preference Eligibility Requirements.
Before completing the Military Service and Veteran's Preference section of the
application, you must read the following to determine your eligibility for preference points.
Only veterans meeting the eligibility requirements can receive preference. Applicants
claiming Veteran's Preference points MUST provide a copy of their DD214 Form.
Eligibility Requirements:
Five points shall be added to a final passing examination score of any person who meets any
ONE of the following conditions:
1. Served on active duty anytime between December 7, 1941 and September 7, 1980; OR
2. A Reservist called to active duty between February 1, 1955 and October 14, 1976
AND who served for more than 180 days; OR
3. A Reservist who entered active duty between October 15, 1976 and October 13, 1982
AND:
a. received a campaign badge or expeditionary medal, OR
b. is a disabled veteran; OR
4. Enlisted in the Armed Forces after September 7, 1980 or entered active duty other than
by enlistment on or after October 14, 1982 AND;
a. completed 24 months of continuous active duty or the full period called or ordered
to active duty or was discharged under 10 U.S.C. 1171 or for hardship under
10 U.S.C. 1173 AND received or was entitled to receive a campaign badge or
expeditionary medal, OR
b. is a disabled veteran.
A Veteran may receive an additional 5 points if s(he) received a Purple Heart Award
(verified by the DD214 Form), or if s(he) has a compensable, service-connected disability.
The disability must be verified by a letter from the Veteran's Administration, dated within the
last 6 months, indicating that the individual is currently receiving disability compensation for a
service-connected disability.
If you would like assistance in determining your eligibility, please call our office.
Be Sure to Sign Your Application.
Unsigned Applications are returned. You may make a photocopy of your completed
application, but each application submitted must contain a signature and current date. If you
have any questions about completing the form please contact one of our counselors for
assistance at (304) 558-3950 Ext. 503.
These 2 Pages of Instructions Are Not Part of The Application.
Please remove these 2 pages from the form after printing.
You do not need to submit these instructions with the form.
Check the printed form to make sure all sections are complete.
1
West Virginia Division of Personnel
APPLICATION FOR EXAMINATION
1900 Kanawha Boulevard, East, Charleston, West Vir
g
inia 25305-0139 304/558-3950 TDD: 304/558-1237
JOB CLASSES FOR WHICH YOU ARE APPLYING:
(
This a
pp
lication cannot be
p
rocessed without
j
ob titles
)
For Office Use Only
(
Do not write in the s
p
aces below.
)
A R V-5( ) V-10( )
A R
A R
A R
1. 2.
Soc. Sec. No.:
- -
Last Name
(
above line
)
First NameMiddle Initial
Mailin
g
Address
(
above line
)
Cit
y
Count
y
State
(
Area Code
)
Home Phone
(
above
)
(
Area Code
)
Business PhoneZi
p
Code
T
yp
e of Em
p
lo
y
ment
y
ou will acce
p
t:YESNOMark with "X". Have
y
ou...
OFFICE USE
A
Permanent Full-Time
applied to the Division of Personnel in the
last 12 months?
B
Permanent Part-Time
C
Temporary Full-Time
Applied using a different name?
If Yes, type name below:
D
Temporary Part-Time
E
Intermittent
Previously held/currently hold a job covered
by the Division of Personnel?
Date you are available to interview:
Date:
Were you born in West Virginia?
Enter county on the line below:
Mark (X) all shifts that apply:
A
Day Shift Only
Can you legally work in the U.S.A? If
temporarily, enter expiration date below:
B Evening Shift Only
C
Night Shift Only
May we send your name to agencies not
covered by the Division of Personnel?
DRotating Shift Only
Have you been convicted of a felony within the
past 7 years
?
YES
NO
A “YES” answer will not cause the removal of your name from an employment register or bar you from all
employment unless the conviction relates to the position for which you are applying.
We provide reasonable accommodations for persons with disabilities. Call our office for assistance.
Select 1 to 10 counties in which you will definitely accept employment. MARK NO MORE THAN 10 COUNTIES.
See map on Web site. Mark with “X”. Mark ALL counties only if you will certainly accept employment in any county.
01Barbour
12Grant23Logan34Nicholas
45Summers
02Berkeley
13Greenbrier24McDowell35Ohio
46Taylor
03Boone
14Hampshire25Marion36Pendleton
47Tucker
04Braxton
15Hancock26Marshall37Pleasants
48Tyler
05Brooke
16Hardy27Mason38Pocahontas
49Upshur
06Cabell
17Harrison28Mercer39Preston
50Wayne
07Calhoun
18Jackson29Mineral40Putnam
51Webster
08Clay
19Jefferson30Mingo41Raleigh
52Wetzel
09Doddridge
20Kanawha31Monongalia42Randolph
53Wirt
10Fayette
21Lewis32Monroe43Ritchie
54Wood
11Gilmer
22Lincoln33Morgan44Roane
55Wyoming
Markonly if available in ALL counties =>
AN EQUAL OPPORTUNITY EMPLOYER
2
Employment History - Resumes will not be accepted in place of this information.
For more about completing this section, please read the instructions pages.
List all work experience beginning with your present or most recent job and work back.
Any change in duties, title, or employment status with the same employer, must be listed as a separate job.
Be sure to show your employment dates and hours worked per week.If you need more space for your duty
description, continue in the next box, or download the Employment History Supplement sheet.
Employer Name and AddressEmployer Phone No.
Type of Business
Name of Supervisor
Your Job TitleLast Salary
Employment Dates
Employment
Status:
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours worked per week Æ
mo. / yr.mo. / yr.
Did you supervise any
employees?
YES
NO
Date you began supervising: (mo. / yr.)List titles and number of Employees you officially supervised:
Detailed Description of Your Duties and Responsibilities:
Em
p
lo
y
er Name and AddressEm
p
lo
y
er Phone No.
Type of Business
Name of Supervisor
Your Job Title Last Salary
Employment Dates
Employment
Status:
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours worked per week Æ
mo. / yr.mo. / yr.
Did you supervise any
employees?
YES
NO
Date you began supervising: (mo. / yr.)List titles and number of Employees you officially supervised:
Detailed Description of Your Duties and Responsibilities:
2
Employment History - Resumes will not be accepted in place of this information.
For more about completing this section, please read the instructions pages.
List all work experience beginning with your present or most recent job and work back.
Any change in duties, title, or employment status with the same employer, must be listed as a separate job.
Be sure to show your employment dates and hours worked per week.If you need more space for your duty
description, continue in the next box, or download the Employment History Supplement sheet.
Employer Name and AddressEmployer Phone No.
Type of Business
Name of Supervisor
Your Job TitleLast Salary
Employment Dates
Employment
Status:
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours worked per week Æ
mo. / yr.mo. / yr.
Did you supervise any
employees?
YES
NO
Date you began supervising: (mo. / yr.)List titles and number of Employees you officially supervised:
Detailed Description of Your Duties and Responsibilities:
Em
p
lo
y
er Name and AddressEm
p
lo
y
er Phone No.
Type of Business
Name of Supervisor
Your Job TitleLast Salary
Employment Dates
Employment
Status:
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours worked per week Æ
mo. / yr.mo. / yr.
Did you supervise any
employees?
YES
NO
Date you began supervising: (mo. / yr.)List titles and number of Employees you officially supervised:
Detailed Description of Your Duties and Responsibilities:
2
Employment History - Resumes will not be accepted in place of this information.
For more about completing this section, please read the instructions pages.
List all work experience beginning with your present or most recent job and work back.
Any change in duties, title, or employment status with the same employer, must be listed as a separate job.
Be sure to show your employment dates and hours worked per week.If you need more space for your duty
description, continue in the next box, or download the Employment History Supplement sheet.
Employer Name and AddressEmployer Phone No.
Type of Business
Name of Supervisor
Your Job TitleLast Salary
Employment Dates
Employment
Status:
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours worked per week Æ
mo. / yr.mo. / yr.
Did you supervise any
employees?
YES
NO
Date you began supervising: (mo. / yr.)List titles and number of Employees you officially supervised:
Detailed Description of Your Duties and Responsibilities:
Em
p
lo
y
er Name and AddressEm
p
lo
y
er Phone No.
Type of Business
Name of Supervisor
Your Job TitleLast Salary
Employment Dates
Employment
Status:
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours worked per week Æ
mo. / yr.mo. / yr.
Did you supervise any
employees?
YES
NO
Date you began supervising: (mo. / yr.)List titles and number of Employees you officially supervised:
Detailed Description of Your Duties and Responsibilities:
2
Employment History - Resumes will not be accepted in place of this information.
For more about completing this section, please read the instructions pages.
List all work experience beginning with your present or most recent job and work back.
Any change in duties, title, or employment status with the same employer, must be listed as a separate job.
Be sure to show your employment dates and hours worked per week.If you need more space for your duty
description, continue in the next box, or download the Employment History Supplement sheet.
Employer Name and AddressEmployer Phone No.
Type of Business
Name of Supervisor
Your Job TitleLast Salary
Employment Dates
Employment
Status:
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours worked per week Æ
mo. / yr.mo. / yr.
Did you supervise any
employees?
YES
NO
Date you began supervising: (mo. / yr.)List titles and number of Employees you officially supervised:
Detailed Description of Your Duties and Responsibilities:
Em
p
lo
y
er Name and AddressEm
p
lo
y
er Phone No.
Type of BusinessName of Your Job TitleLast Salary
Employment Dates
Employment
Status:
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours worked per week Æ
mo. / yr.mo. / yr.
Did you supervise any
employees?
YES
NO
Date you began supervising: (mo. / yr.)List titles and number of Employees you officially supervised:
Detailed Description of Your Duties and Responsibilities:
3
Education. (If you need more space, provide the additional information on a plain sheet of paper.)
Did you receive a high school diploma or high school equivalency diploma (GED)?
YES
NO
Mark highest grade completed. 1 2 3 4 5 6 7
8
9
10
11
12
Additional Education:All academic training, other than high school or GED, must be verified. Verification of
academic training may be in the form of an official transcript, copy of diploma or certificate, or written
statement from an authorized agency verifying possession of the necessary credentials.
School Name and
Address
Field(s) of StudyCredit HoursDates of AttendanceType of
Degree
MajorMinorSem.Quarmo/yrmo/yr
College (Undergraduate)
College (Graduate)
Business, Vocational or Technical
School
Course NameNo. of Weeks
Attended
Hours per
day
Clock hrs.
Completed
Certificate.
Attach copy
Additional training. (Seminars,
Military Trg., Workshops, etc.)
List and provide copies of any licenses and certificates:
Military Service&Veteran's Preference. Completion of this section is voluntary.
Completion of this section is necessary if you are claiming Veteran's Preference Points. Applicants claiming eligibility
MUST provide a copy of their DD214 Form. Five (5) points shall be added to a final passing examination score for any person
who meets the eligibility requirements. Beforemarking this section, please read the Veteran's Preference Eligibility
Requirements stated in the Instructions.
Are you claiming Veteran's Preference for service in the United Stated Armed Forces?
YES
NO
A veteran may receive 5 additional points if he or she receiveda Purple Heart Award, or if s(he) has a verified compensable
service-connected disability. Please see the Instructions section for eligibility requirements.
Are you claiming 5 additional Veteran's Preference Points on the basis of:
Purple Heart Award?
YES
NO
If yes, it must be stated on DD214.
Compensable, service-connected disability?
YES
NO
* If yes, VA letter required. See instructions.
(* Veteran's Administration letter verifying disability must be dated within the last 6 months.)
Identification: When reporting for an examination, you must present identification which includes a signature and/or
picture (ex.: driver's license, Soc. Sec. card, credit cards, passport). Applicants without proper ID will NOT be permitted to
test.
Affirmation. I certify under penalty of law and disqualification that all statements are true and complete. I authorize the
State of West Virginia and any agent acting on its behalf to conduct an inquiry into any job-related information contained in
this application. I release the State of West Virginia and any agent acting on its behalf from any and all liability by reason of
the request for such information. I further authorize and request each former employer, educational institution, or organization
(including law enforcement agencies) to provide all information that may be sought in connection with this application.
Signature:
Date:
Be sure to sign your application.
4
EQUAL EMPLOYMENT SURVEY QUESTIONNAIRE
The following information will be used solely to evaluate recruitment and examination
methods. This form will be kept separate from your application and will not be shared with
hiring agencies. Nothing you write on this form will in any way affect your test score or your
chances for employment. Answering these questions is voluntary; however, your cooperation
is essential for us to ensure equal employment opportunity for all job applicants.
Please enter information as indicated:
Social Security Number
Enter one number per block.
Do not use any dashes.
Date of Birth.
Example: June 3, 1967
would be entered as
06 03 67
Check (X) the
Correct box
below
MoDayYr Male
Female
DISABILITY. A disabled individual is any person who 1) has a disability which substantially
limits one or more of the major life activities, 2) has a record of such impairment, 3) is
regarded as having such an impairment. (Mark “x” in a box below.)
Do you have a disability? YES NO
Please mark (x) the item which best describes your primary racial/ethnic background.
Mark (x) one item only.
1.
BLACK - a person having origins in one of the black racial groups of Africa.
2.
HISPANIC - a person of Mexican, Puerto Rican, Cuban, Central American, South American, or
other Spanish culture or origin, regardless of race.
3.
WHITE - a person having origins in any of the original people of Europe, North Africa, or Middle
East.
4.
AMERICAN INDIAN OR ALASKAN NATIVE - a person having origins in any of the original
people of North America and maintains cultural identification through tribal affiliation or
community recognition.
5.
ASIAN OR PACIFIC ISLANDER- a person having origins in any of the original people of the
Far East, SE Asia, the Indian subcontinent, or any of the Pacific Islands. Example: China, India,
Mark (1,2,3) the most important sources of information below which influenced your decision to apply.
Mark the most important, 1. The next most important, 2. Rank at least 1, but no more than 4.
A
DOP Counselor
Radio Announcement
I
B
DOP Information Booklet
Newspaper
J
C
DOP Recruiter Information
Friend or Neighbor
K
D
Employment Security / Job Service Office
State Employee
L
E
Division of Human Services
State Agency Referral
M
F
High School Counselor / Teacher
DOP Web Site Information
N
G
College Placement Office / Advisor
Other:
O
H
State Vocational Rehabilitation Office
Other:
P
