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- - WEST VIRGINIA JUDICIARY APPLICATION FOR EMPLOYMENT (West Virginia Supreme Court of Appeals)

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Judiciary Employment Application; Rev. 02/2018
Equal Opportunity Employer
Page 1 of 3
WEST VIRGINIA JUDICIARY APPLICATION FOR EMPLOYMENT
We consider applicants for all positions without regard to race, color, religion, sex, age, disability, or national
origin, or any other legally protected status. (Please print below.)
Position(s) Applied for Office Location, County
/ /
Date of Application
Last Name First Name Middle Name
- -
Social Security Number
Home Phone Cell Phone Home County
EDUCATION
High School
Undergraduate
College/University
Graduate/Professional
School Name:
Location
(city/state):
Years Completed:
1 2 3 4 1 2 3 4 1 2 3 4
Diploma
(degree and year):
Indicate Course of
Study or Major:
State any additional educational information you feel may be helpful to us in considering your application:
List any relatives who currently work in the judicial branch, including their position and office locations:
REFERENCES
Give name, address, and telephone number of three references who are not related to you and are not previous
employers:
Name Address Phone Number
1.
2.
3.
Date of Birth
/ /
Home Address City State Zip Code
Judiciary Employment Application; Rev. 02/2018
Equal Opportunity Employer
Page 2 of 3
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. (If you need additional space, continue on a separate sheet of paper.)
Employer
From:
/ /
To:
/ /
Dates of Service
Job Title
Telephone Number
Starting: $ Final: $
Hourly Rate/Salary
Employer's Address
Work Performed
Reason for Leaving
Employer
From:
/ /
To:
/ /
Dates of Service
Job Title
Telephone Number
Starting: $ Final: $
Hourly Rate/Salary
Employer's Address
Work Performed
Reason for Leaving
Signature of Applicant: _________________________________________ Date: ______________________
For AO Use Only:
Investigation Authorized By (print name and title): _______________________________________________________
Signature: ___________________________________________________ Date: ______________________
Judiciary Employment Application; Rev. 02/2018
Equal Opportunity Employer
Page 3 of 3
RELEASE OF INFORMATION
TO WHOM IT MAY CONCERN:
I hereby authorize any representative of the Supreme Court of Appeals of West Virginia bearing this release to
obtain information from the West Virginia State Police files or other sources pertaining to my personal background
including, but not limited to, academic and athletic achievement, attendance, personal history, disciplinary action,
medical credit or any other records you may have regarding me. I hereby direct you to release such information upon the
request of the bearer. This release is executed with the full knowledge and understanding that the information is for the
official use of the Supreme Court of Appeals of West Virginia. Consent is granted for the Supreme Court of Appeals of
West Virginia to furnish such information, as is described above, to third parties in the course of the Supreme Court
fulfilling its official responsibilities with regards to my application for employment. I hereby release you, the institution
or establishment which you represent, including its officers, employees, and related personnel, both individually and
collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs,
family or associates because of compliance with this authorization and request to release information, or any attempt to
comply with it. Should there be any question as to the validity of this release, you may contact me as indicated below:
(This release is valid for one (1) year after the date of execution.)
(Do not sign below until before a notary public.)
Signature of Applicant: _________________________________________ Date: ______________________
STATE OF ____________________________
COUNTY OF __________________________
Taken, subscribed and sworn to before me this ______ day of ______________________, 20______.
My commission expires ________________________. ____________________________________________
Notary Public
(SEAL)
List all other states and years where you have lived.
Position(s) Applied for Office Location, County
/ /
Date of Application
Last Name First Name Middle Name
- -
Social Security Number
Home Phone Cell Phone Home County
Date of Birth
/ /
Home Address City State Zip Code
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- - WEST VIRGINIA JUDICIARY APPLICATION FOR EMPLOYMENT (West Virginia Supreme Court of Appeals)

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Completed 20 July 2020

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