The Virginia Job Application Form is a standardized document used by applicants seeking employment with the Commonwealth of Virginia. This form ensures that all candidates provide the necessary information for their application, including personal details, education, and work experience. It promotes equal opportunity in the hiring process, allowing individuals from diverse backgrounds to apply for positions within state agencies.
The Virginia Job Application form, officially known as DHRM Form 10-012, serves as a crucial tool for individuals seeking employment within the Commonwealth of Virginia. This form is designed to collect essential information about applicants, ensuring a fair and thorough evaluation process. Applicants are required to provide their personal details, including their full legal name, contact information, and the position they are applying for. The form emphasizes the importance of equal opportunity in employment, prohibiting discrimination based on various factors such as race, gender, and disability. Educational background is also a key component, where candidates indicate their highest completed grade and any post-secondary education, along with relevant degrees or certifications. Additionally, the experience section allows applicants to detail their work history, highlighting skills and qualifications that align with the job. Notably, the form includes sections on references, job preferences, and miscellaneous information, such as willingness to travel or work specific shifts. The certification at the end of the application ensures that all information provided is accurate and complete, reinforcing the integrity of the hiring process. Overall, the Virginia Job Application form is a comprehensive document that facilitates a structured approach to employment within state agencies.
DHRM Form 10-012 (Rev. 9/03)
Commonwealth of Virginia
Please print in ink (preferably black) or use typewriter
An Equal Opportunity Employer
Number of attachments
Application for Employment
Position number
Send this application directly to the agency announcing the vacancy.
Employees of the Commonwealth and applicants for employment shall be afforded equal opportunity in all aspects of employment without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender or age.
As a means of accommodation to persons with specific disabilities that prevent them from completing this application, confidential assistance in filling out this application may be obtained by calling the agency to which you are applying.
1.
Position applied for
2. Agency
(one per application)
(Note: Completion of number three is optional. Failure to submit social
3.
Social Security No.
security number on this form will not prohibit employment consideration.
Social security number may be required on other forms prior to employment.)
4.
Full legal name
6.
Home Phone
(
)
Last
First
Middle
5.
Address
7.
Business Phone
( )
8. E-mail Address
City
State
Zip
9.EDUCATION
a.
Check highest grade completed
1
2 3
4 5
6
7
8 9
10
11
12
b.
If you did not complete high school, do you have a high school equivalency diploma?
Yes
No
c.
Check number of years of post high school education
2
3
4
5
Name and Location of Institution
Hrs
Degree
Major or Specialty
Minor
Dates Attended
Received
2.
d. If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date:
10.EXPERIENCE — Use Supplementary Experience Form(s) for additional space. Starting with the most recent, describe ALL paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position.
You may list significantly different jobs within the same organization as separate items. May we contact your present supervisor?
Job Title
Duties:
Employer
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment used
Dates (mo/yr)
to (mo/yr)
Reason for leaving
Full-time
Part-time
Hours/week
Your name if different from present
Number and titles of employees you supervised Equipment used
c. Job Title
d.Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, and special achievements or specialized skills:
e.Automated word processing (specify equipment)
Typing speed
words per minute.
Shorthand speed
words per minute
f. License (to include driver’s), certificate or other authorization to practice a trade or profession.
Type
License Number
Granted by (licensing board)
11.REFERENCES
List names, addresses and relationships of three persons not related to you who know your qualifications:
Name
Relationship
12.MISCELLANEOUS
Check which shift you will accept:
Day
Evening
Night
Rotating
Weekends
Specify shift hours
Check which job status you will accept:
Part-time (specify)
Check which employment status you will accept:
Salaried (benefits)
Hourly (No benefits)
Part-time salaried (leave benefits only)
d.
Are you willing to accept employment which requires you to travel? No
Yes. If yes,
During the day only,
Occasionally overnight,
Frequently overnight.
e.
List the geographic locations in which you are willing to work. If anywhere in Virginia, write “all”
f.
Are you willing to provide your own transportation if necessary for your employment?
No.
g.
For purposes of compliance with The Immigration Reform and Control Act, are you legally eligible for employment in the United States?
No. Under the Immigration Reform and Control Act of 1986, you will be required to fill out a certification verifying that you
are eligible to be employed and verifying your identity. Further, you will be required to provide documentation to that effect should you be
employed.
h.Section 2.2-2804 of the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality of the Commonwealth from employing a person who is required to present himself and submit to the federal Selective Service registration
requirement and failed to do so. If you are/were required to register for the Selective Service, have you done so? Yes No. If no, state reason:
i.For purposes of compliance with Section 2.2-2903 of the Code of Virginia, are you a veteran who received an honorable discharge and has (i) provided more than 180 consecutive days of full-time active- duty in the armed forces of the United States or reserve components thereof, including the National the National Guard, or (ii) has a service-connected disability rating fixed by the United States Veterans Affairs?
Yes No. If yes, did you serve during the Vietnam Conflict (2/28/61-3/7/75)? Yes No
j.Have you ever been convicted* for any violation(s) of law, including moving traffic violations. Yes No If YES, please provide the following:
Description of offense:
Statute or ordinance (if known ): Date of Charge: ; Date of Conviction
County, City, State of Conviction:
(For additional convictions use plain paper. Include all information listed above.)
*Convictions include Virginia juvenile adjudications for Capital Murder, First and Second Degree Murder, Lynching, or Aggravated Malicious Wounding, if you were age fourteen (14) to eighteen (18) when charged.
13.When will you be available to start work? (No date is necessary if you are available as soon as you give two (2) weeks notice.)
Month Day Year
14.CERTIFICATION--Each Application Requires Current Date and Original Signature
I hereby certify that all entries on both sides and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment in the service of the Commonwealth of Virginia. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent that you may contact references, former employers and educational institutions listed regarding this application. I further authorize the Commonwealth to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause shown as determined by the agency head or designee.
Date
Applicant Signature
Pursuant to federal regulations, we collect responses to the questions below for record keeping purposes. This information will NOT be kept with your application for employment. Federal law prohibits unlawful discrimination on the basis of race, color, sex, age, national origin, religion, or disability.
Check the block for the racial or ethnic group with
Check the block for the highest level of education
Check the appropriate block:
which you identify:
you have completed (check only one):
Female
White (includes Arabian)
Less than 8th grade
Male
Black (includes Jamaican, Bahamians and
Completed 8th grade
other Caribbeans of African but not Hispanic
Attended high school
or Arabian descent)
High school graduate or equivalent
Please indicate your date of birth:
/ /
Hispanic (includes persons of Mexican,
Attended college and/or associate degree
Puerto Rican, Central or South American or
College graduate
Position applied for:
other Spanish origin or culture)
Attended graduate school
Position number:
Asian & Asian American (includes Pakistanis,
Master’s degree
Indians & Pacific Islanders)
Graduate study beyond master’s
American Indians (includes Alaskans)
requirements
FOR OFFICE USE ONLY
Ph.D. or professional degree
EEO Category:
How did you find out about this employment opportunity?
Newspaper*
State RECRUIT system
Radio/TV*
Agency Bulletin Board
VEC
Other (please specify)
*specify name of newspaper or other media
DHRM Form 10-012A(Rev. 9/03)
Attachment Number
Supplementary Experience Form
Social Security Number
Position Applied For
Announcement Number
DHRM Form 10-012A(Rev 9/03)
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