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Application for Employment
EducateWV Worksource West Virginia

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.

General Information
Last name
First
Middle initial
Date
Email address
Home phone
Street address
Cell phone
City, State, Zip
How long have you lived here?
years months
Previous address
Are you over 18 years of age?
Yes     No
If not, employment is subject to verification of minimum legal age.
Have you ever applied for employment through EducateWV Worksource West Virginia in the past?
Yes     No
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
Are you currently employed?
Yes     No
If so, may we inquire of your present employer?
Yes     No     N/A
Have you been convicted of a crime in the past ten years, including misdemeanors and summary offenses?
Yes     No
If yes, describe in full:
Position
For what type of employment would you like to apply?
Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodations?
Yes     No
Check all that apply:    Will accept: Part time     Full time     Temporary work
Shift:           Day     Swing     Graveyard     Rotating
Salary Desired:
Date Available:
Education and Training
SchoolName and location of SchoolCourse of studyNumber of years completedDid 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
Employment History (most recent to least recent)
1 Employer
Telephone
Address
Employed (Month and Year)
From To
Job Title
Salary/Wages
Start Last
Specific Duties
Hours per Week
Reason for leaving
Supervisor's Name
May we contact this employer?
Yes     No
 
2 Employer
Telephone
Address
Employed (Month and Year)
From To
Job Title
Salary/Wages
Start Last
Specific Duties
Hours per Week
Reason for leaving
Supervisor's Name
May we contact this employer?
Yes     No
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.
References
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.
NameAddress and Telephone NumberBusiness/RelationshipYears 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
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