Application For Employment Form - West Virginia Judiciary Page 3
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4WEST VIRGINIA JUDICIARY
EMPLOYMENT DATA RECORD
It is the policy of the West Virginia judiciary to provide equal opportunity in employment for all
persons, and to recruit, select, train, promote, retain, and discipline without regard to race, color,
sex, age, disability, religion, sexual orientation, or national origin. Further, it is the policy of the
West Virginia judiciary to maintain a professional workplace in which individuals are accorded
respect, and maintain an environment free of harassment, including verbal or physical conduct
that creates an intimidating or hostile environment for an individual because of a prohibited basis
in this policy.
As an employer with an Equal Employment Opportunity Plan, we comply with
government regulations and related Equal Employment Responsibilities where they apply.
The purpose of this data record is to comply with government record-keeping, reporting, and
other legal requirements in relation to the
West Virginia Judiciary’s Equal Employment Opportunity
Plan. All data records are kept in a confidential file.
Position applied for _____________________ Office Location ____________ County _______
Date: _________________________
Please Print
Name: _____________________________________________
Address: ___________________________________________
City: ____________________ State: ________ Zip: ________
Signature (Blue Ink) __________________________________
Date of Birth: ____________________
Sex:
Male G
Female G
Race/National Origin:
White G
Hispanic or Latino G
American Indian or Alaskan Native G
Black G
Asian G
Native Hawaiian or Other Pacific Islander G
Two or More Races G
Please note: Completion of Sex and Race/National Origin portion of this form is voluntary.
Inclusion or exclusion of this data will not affect any employment decision.
- - - - - - - - - - - - - -
For AO Use Only:
Application: ____________
Interview: ______________
Emp. Offer: ____________
Response: _____________
Page 3 of 4
RELEASE OF INFORMATION
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