Date:
SECTION 1 – Applicant Information
Last Name:	First Name:	M.I.:
Mailing Address:
City:	State:	Zip (9-digit):	-
Home/Cell Phone:	E-mail:
SECTION 2 – Skills and Employment History Information
Do you have a valid Virginia driver’s license?	Yes	No	Driver’s License No.:
Do you have a commercial driver’s license (CDL)?	Yes	No	Expiration Date:
Will it be used as part of your job with the Department of Forestry?	Yes	No
Do you have a current Incident Qualification Card?	Yes	No	(If yes, attach a copy)
What is the last grade completed in school?
School:	Date Completed:
Have you previously worked for the Virginia Department of Forestry?	Yes	No
Where:	Date:
Have you previously worked for other Commonwealth of Virginia agencies?	Yes	No
Where:	Date:
Previous Employer Name:
Address:
City:	State:	Zip (9-digit):	-
SECTION 3 – Emergency Contact Information
Name:
Address:
City:	State:	Zip (9-digit):	-
Home/Cell Phone:	Work Phone:
Employed By:
SECTION 4 – Miscellaneous
What is your general availability (days, nights, weekends)?
Are you willing to accept employment which requires you to travel?	Yes	No
If yes	During the day only	Occasionally overnight
List the geographic locations in which you are willing to work. If anywhere in Virginia, write “all”.
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. You will be required to provide documentation to that effect should you be employed.
Section 2.1-32.1 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:
For purposes of compliance with Section 2.1-1-112 of the Code of Virginia, are you a veteran who received an honorable discharge and served
more than 180 consecutive days of full-time active duty in the US Army, Navy, Air Force, Marines, or reserve components thereof, including
the National Guard?	Yes	No	If yes, did you serve during the Vietnam Conflict (2/28/61-3/7/75)?	Yes	No
SECTION 5 – Certification
This wage position is temporary in nature. Continued employment in a wage capacity is contingent upon availability of funds, staffing needs of the Department and continued availability of work in the position for which employed. Wage employment is not a guarantee, implied or stated, for full-time, regular employment. The Department will set my work schedule/hours. I will be compensated at the agreed upon hourly rate only for hours worked. I understand that if I am injured on the job, workers’ compensation may cover payment for medical expenses. Work hours are not guaranteed; therefore, I am due no compensation for lost wages. I agree to abide by the policies and procedures of the Department of Forestry and the Commonwealth of Virginia. My employment is restricted to a maximum of 1,500 hours per 365-day cycle. I understand that I am not guaranteed to be scheduled to work this maximum number of hours. I understand that I must sign up for direct deposit of my earnings. If I do not have a bank account, I understand that I must sign up for a debit card for receipt of my earnings. I hereby certify that all entries on both sided 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 to 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 to references and former employers and educational institutions listed being contacted 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.
Applicant Name (Print)	Applicant Signature	Date
SECTION 6 – Emergency Work Disclosure for Firefighter or Emergency Response Positions Only
I understand if hired as a firefighter or emergency responder the work is hard and sometimes, I may work more than 12 hours per day. Prompt compliance with my supervisor’s instructions and orders are required at all times. Until the fire is controlled, personnel on the fireline may be compensated for meal periods if work is performed while eating. For personnel in support positions, and fireline personnel after control of the fire, a meal period of at least 30 minutes must be taken for each six hours on duty.
Applicant Name (Print)	Applicant Signature	Date
SECTION 7 – DOF Hiring Manager Use Only (Confidential)
Last Name:	First Name:	M.I.:
SSN:
Hire Date:	Hourly Rate:	Position:
Unit:	Birth Date:
Gender:	Race:
Hiring Manager Name (Print)	Hiring Manager Signature	Date
SECTION 8 – DOF Human Resources Use Only (Confidential)
Employee No.:	Position No.:
Human Resources Name (Print)	Human Resources Signature	Date
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