Dpt Form 10-012 Application For Employment Page 2
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4c. Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops,
special achievements or specialized skills:
d. License (to include driver’s), certificate or other authorization to practice a trade or profession.
Type
License Number
Expiration Date
Granted by (licensing board)
11. REFERENCES
List names, addresses and relationships of three persons not related to you who know your qualifications:
Name
Address
Phone
Relationship
12. MISCELLANEOUS
a. Check which shift you will accept: ___ Day ___ Evening ___ Night ___ Rotating ___ Weekends Specify shift hours
________________
b. Check which job status you would accept: ___ Full-time ___ Part-time (specify)
_______________________________________________
c. Check which employment status you’d 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. For purposes of compliance with the Immigration Reform and Control Act, are you legally eligible for employment in the United States?
___ Yes ___ 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.
g. Are you willing to provide your own transportation if necessary for your employment? ___ Yes ___ No.
h. Section 2.1-32.1 of the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality of the
Commonwealth from employing a person who was 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 2.1-112 of the Code of Virginia, are you a veteran who received an honorable discharge and served
more than 180 consecutive days of full-time active duty in the US Army, Navy, Air Force, Marines, or reserve components thereof, including the
National Guard? ___ 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 and 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 to references and former employers and educational institutions listed being contacted 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
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