Dpt Form 10-012 Application For Employment

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Commonwealth of Virginia
DPT Form 10-012 (Rev. 10/99)
Send this application
Please print in ink (preferably black) or use typewriter
An Equal Opportunity Employer
directly to the agency
Number of attachments _________________
announcing the vacancy.
Application for Employment
Position number _______________________
Employees of the Commonwealth and applicants for
As a means of accommodation to persons with
employment shall be afforded equal opportunity in all
specific disabilities that prevent them from complet-
aspects of employment without regard to race, color,
ing this application, confidential assistance in filling
religion, political affiliation, national origin, disability,
out this application may be obtained by calling the
marital status, gender or age.
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 security
number on this form will not prohibit employment consideration. Social security
3.
Social Security No.__________________________________________
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. Circle highest grade completed
1
2
3
4
5
6
7
8
9
10 11 12
Year Completed ______________
b. If you did not complete high school, do you have a high school equivalency diploma?
Yes
No
Date Received ____________
c. Circle number of years of post high school education
1
2
3
4
5
6
7
Name and Location of Institution
Hrs
Degree Received
Major or Specialty
Minor
Dates Attended
1.
2.
3.
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?
Yes
No
a. Job Title
Duties:
Employer
Address
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment /software used
Dates (mo/yr)
to (mo/yr)
Reason for leaving
Full-time
Part-time
Hours/week
Your name if different from present
b. Job Title
Duties:
Employer
Address
Phone
Type of business
Immediate supervisor
Title
Number and titles of employees you supervised
Salary (start)
(finish)
Equipment /software used
Dates (mo/yr)
to (mo/yr)
Reason for leaving
Full-time
Part-time
Hours/week
Your name if different from present

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