Application For Employment Form - West Virginia Judiciary (Page 2 of 4) in pdf

APPLICANT’S STATEMENT AND RELEASE

I certify that the answers given herein are true and complete to the best of my knowledge.

I authorize an investigation of all statements contained in this application for employment

as may be necessary in arriving at an employment decision.

I hereby authorize the employer to obtain information and records concerning my past

employment, education, military service, and criminal background, if any, as well as information

and records concerning my character and reputation. I hereby also authorize the release of all

such records or reports, including information of a confidential or privileged nature, as well as

photocopies of the same, to the employer in the West Virginia judiciary. I hereby release the

employer in the West Virginia judiciary, and any person or organization providing any

information, from any liability or claim for damage relating to furnishing the information

specified above.

I understand that neither this document nor any offer of employment from the employer

constitute an employment contract unless a specific document to that effect is executed by the

employer and employee in writing.

EMPLOYMENT EXPERIENCE

List your employment experience for the past five years, starting with your present or last job. Include any job-

related military service assignments. You may exclude organizations which indicate race, color, religion, gender,

national origin, disability or other legally protected status.

Employer:______________________________ Dates of Service: From: / /

To: / /

Address:____________________________________________________________________

Telephone number(s):_________________Hourly rate/salary: Starting: $_____ Final: $_____

Job title:____________________________________________________________________

Work performed:_____________________________________________________________

___________________________________________________________________________

Reason for leaving:___________________________________________________________

Employer:______________________________ Dates of Service: From: / /

To: / /

Address:____________________________________________________________________

Telephone number(s):_________________Hourly rate/salary: Starting: $_____ Final: $_____

Job title:____________________________________________________________________

Work performed:_____________________________________________________________

___________________________________________________________________________

Reason for leaving:___________________________________________________________

Signature of applicant

: ________________________ Date: _______________

(Blue ink required)

- - - - - - - - - - - - - - - - - - -

For AO Use Only:

Investigation authorized by: ______________________________________________________________________

(Print name and title)

Date: _____________________________ Signature: _________________________________________________

(Blue Ink Required)

If you need additional space, please continue on a separate sheet of paper.

Page 2 of 4

Judiciary Employment Application 9/13

Application For Employment Form - West Virginia Judiciary Page 2

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