Instructions: Be certain to fill in all spaces on this Application Form. Specify NOT APPLICABLE (N/A) if necessary. ALL INFORMATION WILL BE TREATED CONFIDENTIALLY. IT IS THE POLICY OF EducateWV WORK SOURCE WEST VIRGINIA TO BE FAIR AND EQUITABLE IN ALL ITS RELATIONS WITH ITS EMPLOYERS, EMPLOYEES AND APPLICANTS FOR EMPLOYMENT WITHOUT REGARD TO RACE, COLOR, RELIGION, ANCESTRY, MARITAL STATUS OR DISABILITY.
| Last name |
First |
Middle initial |
Date |
| Email address |
Home phone |
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| Street address |
Cell phone |
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| City, State, Zip |
How long have you lived here? years months |
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| Previous address |
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| Are you over 18 years of age? Yes No If not, employment is subject to verification of minimum legal age. |
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| Have you ever applied for employment through EducateWV Worksource West Virginia in the past? Yes No |
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| Are you legally eligible for employment in the United States? Yes No |
If not, do you have a temporary work permit? Yes No N/A |
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| Are you currently employed? Yes No |
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| If so, may we inquire of your present employer? Yes No N/A |
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| Have you been convicted of a crime in the past ten years, including misdemeanors and summary offenses? Yes No If yes, describe in full: |
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| For what type of employment would you like to apply?
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| Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodations? Yes No | |
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Check all that apply: Will accept: Part time Full time Temporary work Shift: Day Swing Graveyard Rotating | |
| Salary Desired: |
Date Available: |
| School | Name and location of School | Course of study | Number of years completed | Did you graduate/discharge? |
|---|---|---|---|---|
| High School | Yes No | |||
| Vocational/Trade | Yes No | |||
| Business School | Yes No | |||
| College | Yes No | |||
| Military | Yes No | |||
| Other | Yes No |
| Occupational license, certificate or registration | Where issued |
| Occupational license, certificate or registration | Where issued |
| 1 | Employer | Telephone |
| Address | Employed (Month and Year) From To |
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| Job Title | Salary/Wages Start Last |
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| Specific Duties | Hours per Week |
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| Reason for leaving | Supervisor's Name May we contact this employer? Yes No |
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| 2 | Employer | Telephone |
| Address | Employed (Month and Year) From To |
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| Job Title | Salary/Wages Start Last |
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| Specific Duties | Hours per Week |
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| Reason for leaving | Supervisor's Name May we contact this employer? Yes No |
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| Special Skills (List all pertinent skills, equipment, software, etc., that you can perform/operate related to the position for which you are applying) |
| Please describe a project that you have been directly involved with that posed a challenge to you. Be sure to include what made the project challenging. |
| List the names of three persons not related to you, whom you have known at least one year. List as much as information as you can- additional information may need to be provided upon request. | |||
| Name | Address and Telephone Number | Business/Relationship | Years Acquainted |
|---|---|---|---|
| 1. | |||
| 2. | |||
| 3. | |||
| I certify the information contained in this application is true, correct and complete. I understand that, if employed, false statements reported on this application may be considered sufficient cause for dismissal. | |
| Electronic Signature of Applicant (Type your full name here) |
Date |
Thank you for completing your application with
EducateWV Worksource West Virginia