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Application for Employment TEMPORARY EMPLOYMENT ONLY Office of Human Resources #2 John Brewer’s Bay, St. Thomas, US Virgin Islands 00802 http://hrweb.uvi.edu or (340) 693-1410 This application is part of the examination process. You must show that you meet all the education and/or training and experience requirements for the position. Required documentation [Certificates, degrees, diplomas, and/or licenses] as stated on the job announcement must be submitted to the University of the Virgin Islands – Office of Human Resources. If you do not submit these items, your application may not receive further consideration. Position applied for ____________________________________________________________________________________________________ (Use title from Job Announcement) (Job Code Number) Date Available for Work: __________________________ Minimum acceptable Salary: _____________________________ How did you learn about this position? [ ] Newspaper [ ] Internet [ ] Friend/Employee [ ] Other ______________________ Contact Information Name_______________ ___________________ ______________ ______________________________________ Last First M.I. Social Security No. & Date of Birth Address______________________________________________________________________________________________________ Mailing City or Town Zip Code Home Phone No. _____________________ Work Phone No. ___________________ Cell Phone No. ________________________ E-mail Address: __________________________________ ________________________________________________ Emergency Contact/Relationship & Phone# General Information Have you ever filed an application with UVI? [ ] Yes [ ] No If yes, when?________________________________ Have you ever been employed by UVI? [ ] Yes [ ] No If yes, when? ___________________ Please state reason for leaving _________________________________________________________________ Do you have relatives currently employed by UVI or on the Board of Trustees? [ ] Yes [ ] No If yes, state name and department ________________________________________________________________________________ Are you a retiree of the Government Employee Retirement System (GERS) of the Virgin Islands? [ ] Yes [ ] No Education and Training Please submit education documents (i.e. diploma, transcript) along with your application for employment. Do you have a high school diploma or GED certificate? [ ] Yes [ ] No If no, what is the highest grade? ____________ College and Graduate School Education Name/Location of School(s) # of Credits completed Type of Degree Degree Earned (Yes or No) Name: ______________________________________ Job Code Number: __________________________ Are you 18 years or older: [ ] Yes [ ] No If no, please provide proof of eligibility to work. Are you legally eligible for employment in the USVI? [ ] Yes [ ] No (Note: Proof of citizenship or immigration status will be required upon employment) Please list and attach copies of any/all licenses required for this position. Title & State Number Expiration Date (mm/dd/yyyy) ___________________________________________________________ _________________________________ ___________________________________________________________ _________________________________ ___________________________________________________________ _________________________________ Have you ever been convicted of any violation of law other than a minor traffic violation? [ ] Yes [ ] No Note: The existence of a criminal record does not constitute an automatic bar to employment except where required by law. A conviction does not refer to any conviction of a juvenile offense for which the record has been judicially sealed or expunged; any misdemeanor conviction for which probation has successfully been completed and the case dismissed; or any conviction involving marijuana that is over two years old. If yes, explain and give date(s) of conviction(s): _____________________________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Have you ever been convicted of any sex offense or any controlled substance offense? [ ] Yes [ ] No If yes, explain and give date(s) of conviction(s): _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ I hereby certify that every statement I have made on this application and all related attachments, including my resume are TRUE and COMPLETE. I therefore authorize UVI to investigate all statements made on this application for employment and to discuss the results of its investigation with those responsible for hiring. I further authorize UVI to contact my former employer(s) and references or other persons who can verify information; and I give my consent for former employer(s) and other contacted persons to respond to questions pertaining to information on this application, or related to the job for which I am applying. Further, I release from liability such former employer(s) or other persons contacted by and providing information to UVI. I understand that should an investigation at any time disclose any misrepresentation or falsification of information contained in this document, my application will be disapproved and my name removed from any further consideration for employment. I also understand that if I am a current employee of UVI any falsification or misrepresentation of information may lead to disciplinary action up to and including termination. Date: _________________________________ Signature: ____________________________________________________ Name: _____________________________________ Job Code Number: ___________________________ Work Experience (Please provide your most recent five years) Position Title Employer (Company or Organization) Name, Title & Telephone No. of Immediate Supervisor Address of Employer Type of Business Date of Employment (mm/dd/yyyy) Last Salary $ No. of hours worked per week: No. of employees you supervised: Reason for Leaving: Describe your major duties and responsibilities: Position Title Employer (Company or Organization) Name, Title & Telephone No. of Immediate Supervisor Address of Employer Type of Business Date of Employment (mm/dd/yyyy) Last Salary $ No. of hours worked per week: No. of employees you supervised: Reason for Leaving: Describe your major duties and responsibilities: Position Title Employer (Company or Organization) Name, Title & Telephone No. of Immediate Supervisor Address of Employer Type of Business Date of Employment (mm/dd/yyy) Last Salary $ No. of hours worked per week: No. of employees you supervised: Reason for Leaving: Describe your major duties and responsibilities: Name: ________________________________________ Job Code Number: ___________________________ Position Title Employer (Company or Organization) Name, Title & Telephone No. of Immediate Supervisor Address of Employer Type of Business Date of Employment (mm/dd/yyyy) Last Salary $ No. of hours worked per week: No. of employees you supervised: Reason for Leaving: Describe your major duties and responsibilities: Position Title Employer (Company or Organization) Name, Title & Telephone No. of Immediate Supervisor Address of Employer Type of Business Date of Employment (mm/dd/yyyy) Last Salary $ No. of hours worked per week: No. of employees you supervised: Reason for Leaving: Describe your major duties and responsibilities: Professional References Name & Title Company & Address Telephone Number No. of Years Known AFFIRMATIVE ACTION INFORMATION It is the policy of the University of the Virgin Islands to encourage and support equal employment opportunity for all employees and applicants for employment without regard to race, color, ancestry, sex, religious creed, national origin, physical disability, mental disability, medical condition, age, marital status, political affiliation, sexual orientation, or disabled veteran or Vietnam-era veteran status. Employment decisions will be evaluated on the basis of an individual’s skills, knowledge, abilities, job performance and other legitimate qualifications. Answering the following questions will help us meet our recording requirements for the Equal Employment Opportunity commission and our Affirmative Action Program. This information will be kept confidential and separate from your application form. Whether or not you answer these questions have no bearing on your present or future employment with the University of the Virgin Islands. Ethnic Group: [ ] African-American [ ] American Indian [ ] Asian/Pacific Islander [ ] Hispanic [ ] White [ ] Other ____________________________ Gender: [ ] Male [ ] Female Are you disabled? [ ] Yes [ ] No Are you a Vietnam-era veteran?* [ ] Yes [ ] No Are you a disabled veteran?** [ ] Yes [ ] No Are you an “other veteran”?*** [ ] Yes [ ] No * A Vietnam-era veteran is defined as a person who served on active duty for more than 180 days, any part of which occurred during the period August 5, 1964 to May 7, 1975. ** A disabled veteran is defined as a person who is entitled to compensation under the laws administered by the Veterans Administration for Disability, or whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty. ***An “other veteran” is defined as a person who served on active duty during a war or in a campaign or expedition for which a campaign badge, a service medal, or an expeditionary medal has been authorized. “War” includes veterans with active duty service between December 7, 1941 and April 28, 1952, officially designated a World War II. Active duty veterans of Korea, Vietnam, Desert Shield/Storm and other campaigns or expeditions are included because those actions were designated with a campaign badge or medal. Thank you for your help. Please enclose this form with your application.