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Virginia Job Application PDF Details

When looking for a job, you want to make sure that you are as prepared as possible. This includes having all of the necessary paperwork ready. One important document that you will need is a Virginia job application form. The form is used to collect information about you, including your name, address, and contact information. It also asks for your educational history and work experience. By having the form filled out ahead of time, you can save time when applying for jobs.

This knowledge will allow you to understand better the details of the virginia job application before you begin filling it out.

Question	Answer
Form Name	Virginia Job Application
Form Length	6 pages
Fillable?	Yes
Fillable fields	607
Avg. time to fill out	30 min 44 sec
Other names	dhrm form online, va state application for employment form 10 012, dhrm, virginia state job application

12

Form Preview Example


	DHRM Form 10-012 (Rev. 9/03)					Commonwealth of Virginia

	Please print in ink (preferably black) or use typewriter					An Equal Opportunity Employer
	Number of attachments
						Application for Employment
	Position number

Send this application directly to the agency announcing the vacancy.

Employees of the Commonwealth and applicants for employment shall be afforded equal opportunity in all aspects of employment without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender or age.

As a means of accommodation to persons with specific disabilities that prevent them from completing this application, confidential assistance in filling out this application may be obtained by calling the agency to which you are applying.

1.	Position applied for			2. Agency
			(one per application)	(Note: Completion of number three is optional. Failure to submit social
3.	Social Security No.
3.	Social Security No.			security number on this form will not prohibit employment consideration.
				Social security number may be required on other forms prior to employment.)

4.	Full legal name			6.		Home Phone	(		)
		Last	First	Middle
5.	Address			7.		Business Phone			( )
					8. E-mail Address
		City	State	Zip

9.EDUCATION

a.	Check highest grade completed	1	2 3	4 5	6	7	8 9	10			11	12
b.	If you did not complete high school, do you have a high school equivalency diploma?										Yes	No
c.	Check number of years of post high school education			1	2	3	4	5		6	7
Name and Location of Institution				Hrs		Degree				Major or Specialty			Minor	Dates Attended
						Received
1.
2.
3.

d. If you expect to complete an educational program in the near future, please indicate what type of degree or program and expected completion date:

10.EXPERIENCE — Use Supplementary Experience Form(s) for additional space. Starting with the most recent, describe ALL paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position.

You may list significantly different jobs within the same organization as separate items. May we contact your present supervisor?

Yes

No

a.

Job Title

Duties:

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Number and titles of employees you supervised

Salary (start)

(finish)

Equipment used

Dates (mo/yr)

to (mo/yr)

Reason for leaving

Full-time

Part-time

Hours/week

Your name if different from present

b.

Job Title

Duties:

Employer

Address

Phone

Type of business

Immediate supervisor

Title


Salary (start)				(finish)
Dates (mo/yr)				to (mo/yr)
Full-time			Part-time	Hours/week

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

c. Job Title

Duties:

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Number and titles of employees you supervised

Salary (start)

(finish)

Equipment used

Dates (mo/yr)

to (mo/yr)

Reason for leaving

Full-time

Part-time

Hours/week

Your name if different from present

d.Use this space for any additional information you think would help us evaluate your application, including training, seminars, workshops, and special achievements or specialized skills:

e.Automated word processing (specify equipment)

	Typing speed		words per minute.			Shorthand speed			words per minute
f. License (to include driver’s), certificate or other authorization to practice a trade or profession.
	Type				License Number				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 will accept:		Full-time		Part-time (specify)
c.	Check which employment status you will 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.	Are you willing to provide your own transportation if necessary for your employment?						Yes	No.
g.	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.

h.Section 2.2-2804 of the Code of Virginia prohibits any board, commission, department, agency, institution or instrumentality of the Commonwealth from employing a person who is 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 2.2-2903 of the Code of Virginia, are you a veteran who received an honorable discharge and has (i) provided more than 180 consecutive days of full-time active- duty in the armed forces of the United States or reserve components thereof, including the National the National Guard, or (ii) has a service-connected disability rating fixed by the United States Veterans Affairs?

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, 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 that you may contact references, former employers and educational institutions listed 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

Pursuant to federal regulations, we collect responses to the questions below for record keeping purposes. This information will NOT be kept with your application for employment. Federal law prohibits unlawful discrimination on the basis of race, color, sex, age, national origin, religion, or disability.

Check the block for the racial or ethnic group with

Check the block for the highest level of education

Check the appropriate block:

which you identify:

you have completed (check only one):

Female

White (includes Arabian)

Less than 8th grade

Male

Black (includes Jamaican, Bahamians and

Completed 8th grade

other Caribbeans of African but not Hispanic

Attended high school

or Arabian descent)

High school graduate or equivalent

Please indicate your date of birth:

/ /

Hispanic (includes persons of Mexican,

Attended college and/or associate degree

Puerto Rican, Central or South American or

College graduate

Position applied for:

other Spanish origin or culture)

Attended graduate school

Position number:

Asian & Asian American (includes Pakistanis,

Master’s degree

Indians & Pacific Islanders)

Graduate study beyond master’s

American Indians (includes Alaskans)

requirements

FOR OFFICE USE ONLY

Ph.D. or professional degree

EEO Category:

How did you find out about this employment opportunity?

Newspaper*

State RECRUIT system

Radio/TV*

Agency Bulletin Board

VEC

Other (please specify)

*specify name of newspaper or other media

DHRM Form 10-012A(Rev. 9/03)				Attachment Number
			Supplementary Experience Form
Social Security Number				Position Applied For
Name				Announcement Number
Job Title			Duties:

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Type of business

Immediate supervisor

Title


Salary (start)							(finish)
Dates (mo/yr)							to (mo/yr)
Full-time				Part-time				Hours/week
Job Title
Employer
Address

					Phone

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

DHRM Form 10-012A(Rev 9/03)				Attachment Number
			Supplementary Experience Form
Social Security Number				Position Applied For
Name				Announcement Number
Job Title			Duties:

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Job Title

Employer

Address

Phone

Type of business

Immediate supervisor

Title

Salary (start)

(finish)

Dates (mo/yr)

to (mo/yr)

Full-time

Part-time

Hours/week

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

Duties:

Number and titles of employees you supervised Equipment used

Reason for leaving

Your name if different from present

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filling out virginia dhrm preferably part 1

Fill in the Yes, Name, and, Location, of, Institution Hrs, Degree, Received Major, or, Specialty Minor, Dates, Attended Yes, Title, Part, time Phone, finish, tomo, yr and Hours, week field with the particulars required by the system.

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virginia dhrm preferably Month, Year, Day, DayFulltime, Evening, SalariedbenefitsNo, NightRotatingParttimespecify, Occasionallyovernight, Frequentlyovernight, Weekends, Specifyshifthours, HourlyNobenefitsYesIfyes, Duringthedayonly, Parttimesalariedleavebenefitsonly, and Yes blanks to complete

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