applied to the Division of Personnel in the
last 12 months?
Applied using a different name?
If Yes, type name below:
Previously held/currently hold a job covered
by the Division of Personnel?
Date you are available to interview:
Were you born in West Virginia?
Enter county on the line below:
Mark (X) all shifts that apply:
Day Shift Only
Can you legally work in the U.S.A? If
temporarily, enter expiration date below:
B Evening Shift Only
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
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.
12 Grant 23 Logan 34 Nicholas
13 Greenbrier 24 McDowell 35 Ohio
14 Hampshire 25 Marion 36 Pendleton
15 Hancock 26 Marshall 37 Pleasants
16 Hardy 27 Mason 38 Pocahontas
17 Harrison 28 Mercer 39 Preston
18 Jackson 29 Mineral 40 Putnam
19 Jefferson 30 Mingo 41 Raleigh
20 Kanawha 31 Monongalia 42 Randolph
21 Lewis 32 Monroe 43 Ritchie
22 Lincoln 33 Morgan 44 Roane
Mark only if available in ALL counties =>
AN EQUAL OPPORTUNITY EMPLOYER