Fillable Printable Application Form for State of West Virginia
Fillable Printable Application Form for State of West Virginia
Application Form for State of West Virginia
West Virginia Division of Personnel
APPLICATION FOR EXAMINATION – INSTRUCTIONS
You may apply online at: www.state.wv.us/admin/personnel
IMPORTANT: You should apply online if at all possible. You may apply from any internet
connected computer. This may include your home, at many libraries, schools, and most
Workforce WV Job Services offices. Applying online speeds processing. You should ONLY
use a paper application if the job announcement does not allow online applications, or you
cannot complete the online application form.
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.
Social Security Number Required.
Pursuant to Section 7 of the Privacy Act of 1974, your disclosure of your social security number is mandatory. We
require social security numbers to verify your identity and confirm the information you provide in your
application. Failure to provide your social security number will result in rejection of your application.
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/personnel . 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 at the
top of page 1 on the form. If you apply online, you do not need to mail your application or take it to the test site.
A photocopy of the application with signature and current date is acceptable. A resume cannot be substituted for
the 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 the counties in which you are
definitely available for work. 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
may be required. Please read the job posting for details. 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.
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. Furthermore, it is a violation of state law for any person to use
any official authority or influence to attempt to secure for any person an advantage in appointment to a position in
the classified service.
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. 57207.
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 Virginia 25305-0139 304/558-3950
JOB CLASSES FOR WHICH YOU ARE APPLYING:
(This application cannot be processed without job titles)
For Office Use Only
(Do not write in the spaces below.)
A R V-5( ) V-10( )
A R
A R
A R
1. 2.
Soc. Sec. No.:
-
-
< See SSN Note in instructions
Last Name (above line)
First Name
Middle Initial
Mailing Address (above line)
City
County
State & Zip
(Area Code) Home Phone (above)
Business Phone
E-mail Address
Type of Employment you will accept:
YES
NO
Mark with "X".
OFFICE USE
A
Permanent Full-Time
Have you applied to the Division of
Personnel in the last 12 months?
B
Permanent Part-Time
C
Temporary Full-Time
Have you applied using a different name?
If Yes, type name below:
D
Temporary Part-Time
E
Intermittent
Have you 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:
here:
B
Evening Shift Only
C
Night Shift Only
May we send your name to agencies not
covered by the Division of Personnel?
D
Rotating 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 the counties in which you will definitely accept employment.
See map on Web site. Mark with “X”. Mark ALL counties only if you will certainly accept employment in any county.
01
Barbour
12
Grant
23
Logan
34
Nicholas
45
Summers
02
Berkeley
13
Greenbrier
24
McDowell
35
Ohio
46
Taylor
03
Boone
14
Hampshire
25
Marion
36
Pendleton
47
Tucker
04
Braxton
15
Hancock
26
Marshall
37
Pleasants
48
Tyler
05
Brooke
16
Hardy
27
Mason
38
Pocahontas
49
Upshur
06
Cabell
17
Harrison
28
Mercer
39
Preston
50
Wayne
07
Calhoun
18
Jackson
29
Mineral
40
Putnam
51
Webster
08
Clay
19
Jefferson
30
Mingo
41
Raleigh
52
Wetzel
09
Doddridge
20
Kanawha
31
Monongalia
42
Randolph
53
Wirt
10
Fayette
21
Lewis
32
Monroe
43
Ritchie
54
Wood
11
Gilmer
22
Lincoln
33
Morgan
44
Roane
55
Wyoming
Mark only 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 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. Space is provided for 8 entries.
Employer Name and Address
Employer Phone No.
Type of Business
Name of Supervisor
Your Job Title
Last Salary
Employment Dates
Employment
Status. Check
Paid Employment
Volunteer Work
Full-
time
Part-time
Type Number of hours per week: --->
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:
Employer Name and Address
Employer Phone No.
Type of Business
Name of Supervisor
Your Job Title
Last Salary
Employment Dates
Employment
Status. Check
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours per week: -
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
Employment History - Resumes will not be accepted in place of this information.
For more about this section, please read the instructions pages.
Continue Employment History. There is space for eight (8) entries. Make copies of this sheet if you need more space.
Employer Name and Address
Employer Phone No.
Type of Business
Name of Supervisor
Your Job Title
Last Salary
Employment Dates
Employment
Status. Check
Paid Employment
Volunteer Work
Full-
time
Part-time
Type Number of hours per week: --->
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:
Employer Name and Address
Employer Phone No.
Type of Business
Name of Supervisor
Your Job Title
Last Salary
Employment Dates
Employment
Status. Check
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours per week: -
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:
4
Employment History - Resumes will not be accepted in place of this information.
For more about this section, please read the instructions pages.
Continue Employment History. There is space for eight (8) entries. If you need more space for your duty description,
continue in the next box, or download the Employment History Supplement sheet.
Employer Name and Address
Employer Phone No.
Type of Business
Name of Supervisor
Your Job Title
Last Salary
Employment Dates
Employment
Status. Check
Paid Employment
Volunteer Work
Full-
time
Part-time
Type Number of hours per week: --->
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:
Employer Name and Address
Employer Phone No.
Type of Business
Name of Supervisor
Your Job Title
Last Salary
Employment Dates
Employment
Status. Check
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours per week: -
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:
5
Employment History - Resumes will not be accepted in place of this information.
For more about this section, please read the instructions pages.
Continue Employment History. There is space for eight (8) entries. If you need more space for your duty description,
continue in the next box, or download the Employment History Supplement sheet.
Employer Name and Address
Employer Phone No.
Type of Business
Name of Supervisor
Your Job Title
Last Salary
Employment Dates
Employment
Status. Check
Paid Employment
Volunteer Work
Full-
time
Part-time
Type Number of hours per week: --->
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:
Employer Name and Address
Employer Phone No.
Type of Business
Name of Supervisor
Your Job Title
Last Salary
Employment Dates
Employment
Status. Check
Paid Employment
Volunteer Work
Full-
time
Part-time
Number of hours per week: -
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:
6
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 Study
Credit Hours
Dates of Attendance
Type of
Degree
Major
Minor
Sem.
Quar
mo/yr
mo/yr
College (Undergraduate)
College (Graduate)
Business, Vocational or Technical
School
Course Name
No. of Weeks
Attended
Hours per
day
Clock hrs.
Completed
Certificate.
Attach copy
Additional training. (Seminars,
Military Trg., Workshops, etc.)
In the space below, list any related licenses and certificates. (Verification copies must be provided.)
If you have a Commercial Driver's License (CDL), enter your License Number, CDL License Class, and Expiration
Date. If properly completed you do not have to send a copy of your CDL.
Military Service and 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. Before marking 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 received a 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).
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.
7
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, 1977
would be entered as
06 03 77
Check (X) the
Correct box
below
Mo
nth
Day
Yr
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,
Japan, Korea, the Philippines, and Samoa.
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
