Application for Examination Instructions - West Virginia

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 Name Middle Initial
Mailin
g
Address
(
above line
)
Cit
Count
y
State
(
Area Code
)
Home Phone
(
above
)
(
Area Code
)
Business Phone Zi
p
Code
T
yp
e of Em
p
lo
y
ment
y
ou will acce
p
t: YES NO Mark 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?
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 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.
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
Page 3/9
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