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
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 – Agreement
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 certify that the information on this application is true and correct to the best of my knowledge. Providing false information is grounds for immediate termination of my wage employment
Applicant Name (Print)	Applicant Signature	Date
SECTION 5 – 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 6 – VDOF 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 7 – VDOF Human Resources Use Only (Confidential)
Employee No.:	Position No.:
Human Resources Name (Print)	Human Resources Signature	Date
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