Fillable PLEASE TYPE IN SHADED BOXES 2. Permanent Mailing (West Virginia Division of Natural Resources)

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PLEASE TYPE IN SHADED BOXES 2. Permanent Mailing (West Virginia Division of Natural Resources)

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  • 50 check-boxes
  • 70 other fields

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File type: PDF

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BROWSE WEST VIRGINIA DIVISION OF NATURAL RESOURCES FORMS

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PLEASE TYPE IN SHADED BOXES
1. Name
Last First Middle
2. Permanent Mailing Address
3. Social Security Number
4. Telephone Number
(Home)
(School/Work)
5. For which position(s) are you applying?
6. Are you a citizen of the United States?
Yes No
7. If hired, can you submit proof
of U.S. citizenship or proper work
authorization?
Yes No
8. How long have you been a resident
of West Virginia?
9. If hired, can you provide a valid
West Virginia driver’s license?
Yes No
10. When would you be available to begin work?
When would you expect to leave?
11. Rate of pay expected?
12. Are you 18 years of age or older?
Yes No
13. Are you willing to travel?
Yes No
14. Where in West Virginia could you work?
County?
Facility?
Employees are responsible for providing own transportation,
locating living quarters and making meal arrangements.
15. Have you ever worked for the State of
West Virginia under a different name?
If so, explain.
16. Have you ever taken any examinations
under the West Virginia Division of Personnel?
Yes No
17. If yes, for which positions?
18. Because of business associations, would there
be any conflict of interest in you working for the
State of West Virginia?
Yes No
STATE OF WEST VIRGINIA
APPLICATION FOR
TEMPORARY EMPLOYMENT
RETURN THIS COPY TO:
WV Division of Natural Resources
Section: ______________________
324 4th Avenue
South Charleston, WV 25303
Or to the individual facility where you are
seeking employment.
Any temporary employee may be terminated, reassigned, or placed on a reduced or
intermittent work schedule, or may have their temporary employment discontinued any time
during the employment period at the discretion of the agency.
RECORD OF EDUCATION
Check last grade completed: 1 2 3 4 5 6 7 8 9 10 11 12
SCHOOL NAME AND ADDRESS OF SCHOOL MAJOR/
MINOR
DID YOU
GRADUATE?
DIPLOMA OR
DEGREE
ELEMENTARY
Yes No
HIGH
Yes No
COLLEGE
Yes No
OTHER
(SPECIFY)
Yes No
STATEMENT OF POLICY REGARDING THE EQUAL OPPORTUNITY TO USE FACILITIES AND PARTICIPATE IN PROGRAMS
“It is the policy of the State of West Virginia to provide its facilities, accommodations, services and programs to all persons without
regard to sex, race, color, age, religion, national origin or disability. Proper licenses, registration and compliance with official rules
and regulations are the only sources of restrictions for facility use or program participation.”
“The State of West Virginia is an equal opportunity employer.”
RECORD OF MILITARY SERVICE
Were you in the U.S. Armed Forces?
Yes No
If yes, what branch?
Date of Entry (or Entries)
Date of Last Separation
Rank at Discharge Service Number
List duties in the Service, including special training
Have you taken any training under the G.I. Bill of Rights?
Yes No
If yes, what training did you take?
EMPLOYMENT HISTORY
NAME OF COMPANY EMPLOYED FROM
ADDRESS TO
TYPE OF BUSINESS
LAST POSITION HELD STARTING SALARY
NAME OF SUPERVISOR
DESCRIBE THE WORK YOU DID LAST SALARY
PART TIME
REASON OF LEAVING FULL TIME
NAME OF COMPANY EMPLOYED FROM
ADDRESS TO
TYPE OF BUSINESS
LAST POSITION HELD STARTING SALARY
NAME OF SUPERVISOR
DESCRIBE THE WORK YOU DID LAST SALARY
PART TIME
REASON OF LEAVING FULL TIME
PERSONNEL REFERENCES (NOT FORMER EMPLOYERS OR RELATIVES)
NAME 1. 2. 3.
ADDRESS
OCCUPATION
PHONE NUMBER
What other statements would you care to make regarding your qualifications for the position you seek, or other training
experiences, or abilities you have that you feel would contribute to your working expertise?
Have you previously been employed by West Virginia State Parks & Recreation?
Yes No
If yes, what facility? Location?
If lifeguard, check appropriate rating:
Basic Lifeguarding Lifeguard Training Lifeguard Instructor Expiration Date
Typing WPM Shorthand WPM
STATEMENT OF APPLICANT
“I hereby affirm that this application contains no willful misrepresentations or falsifications and that information given by me is true and
complete in the best of my knowledge and belief. I am aware that should investigation at any time disclose any such misrepresentation or
falsifications, I shall be subject to dismissal.”
Date Signature of Applicant_______________________________________________________
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PLEASE TYPE IN SHADED BOXES 2. Permanent Mailing (West Virginia Division of Natural Resources)

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Completed 1 November 2020

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