DPTI Forml 10-012(Rev, 10/99) Please printi ini ink (preferably! black)oru use typewriter Numberc ofattachments Position number  Commonwalhorvirgna Ank EqualOpportuniby. Emplayer Application for Employment  Send this application directlyt tot the: agency announcing the vacancy.  Asa al meansofacommodation tol persons with specific disabilities thatpreventt them from completingt this application, confidentialasistaneei in filling out this application maybe obtainedbyo calling thea agencyto which youare applying,  Employees ofthe Commonwealhandapliamsforempboyment shall aastwulwpmyht: aspectsofemployment without regardt to race, color, religion, polalariatio.niomil origin, disability, maritalstatus.gender. orage.  1. Position applied for 3. Social Security 4. Fulll legal name 5. Address  2. Agency  (onep pera application)  (Note: Completion ofmumber dreei is optional. Failuretos submit social securitynumber on this/ fomm willnoip prohibite empbyeitconslraion, Socialsecurityr number may berequired ono otherforns priorto emplayment.)  No.  6. Home Phone 7. Business Phone  First Slate  Middle Zip  Last City  EDUCATION - Check highest grade completed Name and Location ofInstitution  Di 000400A0010100 11 012  Year Completed  Yes No Date Received  b. Ifyou didi not complete high school, do you! have al high school equivalency diploma? D5  7 Major or Specialty  Check number ofs years ofp post! highs schoole education  01 02 D3D 04 060  Hrs  Degree Received  Minor Dates Attended  I. 2. 3.  d. Ifyou expect to complete an educational program int the near future, please indicate what type of degree or program ande expected 9. EXPERIENCE- Uses Supplementary Highlightyourk knowledge, skillsa andabilities whichbest demonstrate: yourqualificationsf fort thisp position., applicables voluntayexperimce. jobs withinthes sameorganizationas: separateitems. May we contacty yourp present supervisor?  completion date:  Experience Fom(,oradaitiond. space. Startingwitht themostr recemtdeseribeALLP paid,n military and  D Yes No  Your mayl listsignificantlys differentj Job' Title Employer Address Type ofb business Immediate supervisor Title Salary (start) Dates (mo/yr) Full-time Part-time b. Job' Title Employer Address Type ofb business Immediate supervisor Salary Title (start) Dates (mo/yr) Full-time Part-time  Duties:  Phone  Number and titles ofe employees you supervised Equipment used Reason for leaving Your name ifdifferent from present Duties:  (finish) to (mo/yr) Hours/week  Phone  Number and titles of employees yous supervised Equipment used Reason for leaving Your name ifdifferent from present  (finish) to (mo/yr) Hours/week    Job' Title Employer Address Type oft business Immediate supervisor Title Salary (start) Dates (mo/yr) Full-time Part-time  Duties:  Phone  Number and titles of employees yous supervised Equipment used Reason for leaving Your name ifdifferent from present  (finish) to (molyr) Hours/week  d. Uset this space for any additional information you think would! help us evaluate your application, including training, seminars, workshops,  and special achievements or specialized skills: Automated word processing (specify equipment)  Typing speed Type  words per minute.  Shorthand speed  words per minute  License (to include driver's), certificate or other authorization to practice at trade orp profession.  License Number  Granted by (licensing board)  10. REFERENCES  Listnames,adéressandrehatomhpsortame, personsnotr relatedtoy youy whol know) yourqualifications:  Name  Address  Phone  Relationship  11. MISCELLANEOUS Check whichs shiftyouv will accept: b. Checky whichj obsansyouwoudaeept: D Full-time Check which employment status you' d accept: d. Arey you willing to accept employment which requires you tot travel? D No Occasionally overnight, D Frequently overnight.  DI Day D Evening a Night D Rotating D Weekends Specify shift hours  D Part-time (specify)  D Salaried (benefits) DH Hourly (No! benefits) D1 Part-time salaried (leave! benefits only)  Yes. Ifyes, D Duringt the day only,  Listt the geographic locations in which you are willing to work. Ifanywhere in Virginia, write "all"  For purposes of compliance with" The Immigration Reform and Control. Act, are youl legally eligible for employment in thel United States? Yes D No. Under thel Immigration Reform and Control Acto of1 1986, you will be required to fill outa certification verifying that you are eligible tol be employed and verifying your identity. Further, you will be required toj provide documentation to that effect should youb be h. Section 2.1-32.1 oft the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality ofthe Commonwealth from employing aj person whoi is required to present himself and submit to the federal Selective Service registration requirement and failed to do so. Ify you are/were required tor register for the Selective Service, have you done so? D Yes D No.  employed.  g. Arey you willing top provide your own transportation if necessary for your employment? D Yes D No.  Ifno, state reason:  For purposes of compliance with Section 2.1-112 oft the Code of Virginia, are you a veteran who received an! honorable discharge ands served more than 180 consecutive days offull-time active duty in the US Army, Navy, Air Force, Marines, orr reserve components thereof, including thel National Guard? Havey you ever been convicted* for any violation(s) ofl law, including moving traffic violations. D Yes D NoIf YES, please provide thei following:  J Yes D No.) Ifyes, did yous serve during the Vietnam Conflict (2/28/61-3/7/75)? D Yes[ D No  Description ofc offense: Statute or ordinance(if known) ): Date of Charge: County, City, State of Conviction: (Fora additionalconvictionsi useplain paper. Includez alli information! listedabove.) fourteen (14)toe eighteen(18) whencharged. Month Day  Date of Conviction  *Convictions include Virginiaj juvenile adjudications for CapitalMurder, Firsta ands SecondI DegreeMurder, PaigAFMasNs Wounding, ifyouwereage  12. When willy you beavailableto start work? (No datei isr necssaryifyouare: availablea ass soonas youg give two (2)weeks notice.)  Year  13. CERTIFICATION-Fachx Application Requires Current Date and Original Signature  Ihereby certify that alle entries onbothsides: anda attachments aretrue: and complete, andI agree andu understand thata any Alsifiemtionofinbomation herein, regardlessof timec ofdiscovery, mayo cause forfeiture ont mypartt toa any employmenti in theserviceofthe CommponwvalihofVitgnia.l Iunderstand thata alli information onthisa application iss subjectt to verificationandI consentt to criminall hsoyladegumdchaal. alsoconsentt to references andf former employers: andeducational institutions listed being contactedr regarding this application. Ifurthera authorizethe Commonwealth tor relyuponanduse,: asi its seesf fit, anyi informationr receivedfromsuch: contacts. Information containedon thisa applicationmayt bec disseminatedt to other agencies, nongovernmental organizations or systems ona aneed- to- know basis forg goodcause shownas  determinedbythe: agency! heado ordesignee.  Date  Applicant Signature    Job' Title Employer Address Type oft business Immediate supervisor Title Salary (start) Dates (mo/yr) Full-time Part-time Job' Title Employer Address Type oft business Immediate supervisor Title Salary (start) Dates (mo/yr) Full-time Part-time Job' Title Employer Address Type of business Immediate supervisor Title Salary (start) Dates (mo/yr) Full-time Part-time Job Title Employer Address Type oft business Immediate supervisor Title Salary (start) Dates (mo/yr) Full-time Part-time Job Title Employer Address Type of business Immediate supervisor Title Salary (start) Dates (mo/yr) Full-time Part-time  Duties:  Phone  Number and titles of employees yous supervised Equipment used Reason for leaving Your name ifd different from present Duties:  (finish) to (mo/yr) Hours/week  Phone  Number andt titles of employees yous supervised Equipment used Reason for leaving Your name ifdifferent from present Duties:  (finish) to (mo/yr) Hours/week  Phone  Number and titles of employees you supervised Equipment used Reason for leaving Your name ifdifferent from present Duties:  (finish), to (mo/yr) Hours/week  Phone  Number and titles of employees you supervised Equipment used Reason forl leaving Your name ifdifferent from present Duties:  (finish) to (mo/yr) Hours/week  Phone  Number and titles of employees yous supervised Equipment used Reason for leaving Your name ifdifferent from present  (finish) to (mo/yr) Hours/week