Fillable Printable State Application 7.0 Format of Floyd County
Fillable Printable State Application 7.0 Format of Floyd County
State Application 7.0 Format of Floyd County
DHRM Form 10-012 (Rev. 9/03)
Please print in ink (preferably black) or use typewriter
Number of attachments
Position number
Commonwealth of Virginia
An Equal Opportunity Employer
Application for Employment
Send this application
directly to the agency
announcing the vacancy.
Employees of the Commonwealth and applicants for employment
shall be afforded equal opportunity in all aspects of employment
without regard to race, color, religion, political affiliation, national
origin, disability, marital status, gender or age.
As a means of accommodation to persons with specific
disabilities that prevent them from completing this application,
confidential assistance in filling out this application may be
obtained by calling the agency to which you are applying.
1. Position applied for 2. Agency
(one per application)
(Note: Completion of number three is optional. Failure to submit social
3. Social Security No.
security number on this form will not prohibit employment consideration.
Social security number may be required on other forms prior to employment.)
4. Full legal name 6. Home Phone ( )
Last First Middle
5. Address 7. Business Phone ( )
8. E-mail Address
City State Zip
9. EDUCATION
a. Check highest grade completed
1 2 3 4 5 6 7 8 9 10 11 12
b. If you did not complete high school, do you have a high school equivalency diploma?
Yes No
c. Check number of years of post high school education
1 2 3 4 5 6 7
Name and Location of Institution Hrs Degree
Received
Major or Specialty Minor Dates Attended
1.
2.
3.
d. If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected
com
p
letion date:
10. EXPERIENCE — Use Supplementary Experience Form(s) for additional space. Starting with the most recent, describe ALL paid, military and applicable
voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position.
You may list significantly different jobs within the same organization as separate items. May we contact your present supervisor?
Yes No
a. Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
b
. Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
c. Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
d. Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops,
and special achievements or specialized skills:
e. Automated word processing (specify equipment)
T
yp
in
g
s
p
ee
d
words
p
er minute. Shorthand s
p
ee
d
words
p
er minute
f. License
(
to include driver’s
),
certificate or other authorization to
p
ractice a trade or
p
rofession.
Type License Number Granted by (licensing board)
11. REFERENCES
List names, addresses and relationships of three persons not related to you who know your qualifications:
Name Address Phone Relationship
12. MISCELLANEOUS
a. Check which shift you will accept: Day Evening Night Rotating Weekends Specify shift hours
b
. Check which
j
ob status
y
ou will acce
p
t: Full-time Part-time
(
s
p
ecif
y)
c. Check which em
p
lo
y
ment status
y
ou will acce
p
t: Salaried
(
benefits
)
Hourl
y
(
No benefits
)
Part-time salaried
(
leave benefits onl
y)
d. Are you willing to accept employment which requires you to travel? No Yes. If yes, During the day only,
Occasionally overnight, Frequently overnight.
e. List the geographic locations in which you are willing to work. If anywhere in Virginia, write “all”
f. Are
y
ou willin
g
to
p
rovide
y
our own trans
p
ortation if necessar
y
for
y
our em
p
lo
y
ment? Yes No.
g. For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?
Yes No. Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you
are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to that effect should you be
employed.
h. Section 2.2-2804 of the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality of the
Commonwealth from employing a person who is required to present himself and submit to the federal Selective Service registration
requirement and failed to do so. If you are/were required to register for the Selective Service, have you done so?
Yes No.
If no, state reason:
i. For purposes of compliance with Section 2.2-2903 of the Code of Virginia, are you a veteran who received an honorable discharge and has (i) provided
more than 180 consecutive days of full-time active- duty in the armed forces of the United States or reserve components thereof, including the National
the National Guard, or (ii) has a service-connected disability rating fixed by the United States Veterans Affairs?
Yes No. If yes, did you serve during the Vietnam Conflict (2/28/61-3/7/75)? Yes No
j. Have you ever been convicted* for any violation(s) of law, including moving traffic violations.
Yes No If YES, please provide the following:
Description of offense:
Statute or ordinance (if known ): Date of Charge: ;
Date of Conviction
County, City, State of Conviction:
(For additional convictions use plain paper. Include all information listed above.)
*Convictions include Virginia juvenile adjudications for Capital Murder, First and Second Degree Murder, Lynching, or Aggravated Malicious Wounding, if you were age
fourteen (14) to eighteen (18) when charged.
13. When will you be available to start work? (No date is necessary if you are available as soon as you give two (2) weeks notice.)
Month
Day
Year
14. CERTIFICATION--Each Application Requires Current Date and Original Signature
I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of
time of discovery, may cause forfeiture on my part of any employment in the service of the Commonwealth of Virginia. I understand that all information on this application
is subject to verification and I consent to criminal history background checks. I also consent that you may contact references, former employers and educational institutions
listed regarding this application. I further authorize the Commonwealth to rely upon and use, as it sees fit, any information received from such contacts. Information
contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as
determined by the agency head or designee.
Date
Applicant Signature
Pursuant to federal regulations, we collect responses to the questions below for record keeping purposes. This information will NOT be kept with your application for
employment. Federal law prohibits unlawful discrimination on the basis of race, color, sex, age, national origin, religion, or disability.
Check the block for the racial or ethnic group with
which you identify:
Check the block for the highest level of education
you have completed (check only one):
Check the appropriate block:
Female
White (includes Arabian) Less than 8th grade Male
Black (includes Jamaican, Bahamians and Completed 8th grade
other Caribbeans of African but not Hispanic
Attended high school
or Arabian descent) High school graduate or equivalent Please indicate your date of birth: / /
Hispanic (includes persons of Mexican, Attended college and/or associate degree
Puerto Rican, Central or South American or
College graduate Position applied for:
other Spanish origin or culture)
Attended graduate school Position number:
Asian & Asian American (includes Pakistanis, Master’s degree
Indians & Pacific Islanders) Graduate study beyond master’s
American Indians (includes Alaskans) requirements
FOR OFFICE USE ONLY
Ph.D. or professional degree EEO Category:
How did you find out about this employment opportunity?
Newspaper* State RECRUIT system
Radio/TV* Agency Bulletin Board
VEC Other (please specify)
*specify name of newspaper or other media
DHRM Form 10-012A(Rev. 9/03) Attachment Number
Supplementary Experience Form
Social Security Number Position Applied For
Name Announcement Number
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
DHRM Form 10-012A(Rev 9/03) Attachment Number
Supplementary Experience Form
Social Security Number Position Applied For
Name Announcement Number
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different f
r
om
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason fo
r
leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
Job Title
Duties:
Em
p
lo
y
e
r
Address
Phone
T
yp
e of business
Immediate su
p
erviso
r
Title
Number and titles of em
p
lo
y
ees
y
ou su
p
ervise
d
Salar
y
(
start
)
(
finish
)
E
q
ui
p
ment use
d
Dates
(
mo/
y
r
)
to
(
mo/
y
r
)
Reason for leavin
g
Full-time
Part-time
Hours/week
Your name if different from
p
resent
