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"Doing the People's Business" Government of the United States Virgin Islands Employment Application An Equal Opportunity Employer Return ALL applications and support documents to: GERS Bldg., 3rd Floor ☼ 48B-50C Kronprindsens Gade ☼ St. Thomas, U.S.V.I. 00802 ☼ (340) 774-8588 ☼ Fax (340) 714-5040 Orange Grove Shopping Center ☼ Bays #6,7, & 8 ☼ Christiansted, St. Croix, U.S.V.I 00820 (340) 773-0341 ☼ Fax (340) 773-5669 If needed, attach additional sheets, using the same format as on the application. Resumes may be attached to provide additional information. GENERAL INSTRUCTIONS • Type or print clearly in ink this application in its entirety. • Specify the position for which you are applying. Applications will be processed ONLY for vacant positions. • Your application and accompanying (birth certificate, social security card, educational documents, proof of citizenship, training certificates, resume, photo ID, DD 214) materials are confidential and become the property of the Division of Personnel for the Government of the Virgin Islands. • Applications that are received unsigned will not be processed and all information you submit is subject to verification. • Applications are valid for one (1) year from date of receipt and must be upgraded on a yearly basis. • Resumes will not be accepted in lieu of completing application HOW DO WE CONTACT YOU: ____________________________________________________ First Name M.I. Last Name _______________________________________________________________________________ Social Security Number _______________________________________________________________________________ Mailing Address ___________________________________________ Physical Address ___________________________________________ City State Zip Code _______________________________________________________________ Home Phone Business Phone Cellular Phone ______________________________________________________________________________ E-Mail Address POSITION (S) APPLIED FOR: X _____________________________________________ Y_____________________________________________ Z_____________________________________________ St. Thomas St. Croix St. John EDUCATION High School, College, University or Professional School: (An Official Transcript may be required) Dates of Attendance (Month/Year) Credit Hours Earned Name of School Location From To Qtr Sem. Course of Study Type of Degree JOB RELATED TRAINING AND COURSE WORK Vocational, Trade, Government, Business, Armed Forces, etc. Dates of Attendance (Month/Year) Credit Hours Earned Training Completed? Name of School Location From To Class Clock Course of Study YES NO LICENSURE, REGISTRATION, CERTIFICATION (Examples: RN, LPN, PE, CPA, etc.) License, Registration or Certification Number Date Received Expiration Date Government of the Virgin Islands – Employment Application PERIODS OF EMPLOYMENT Describe your work experience in detail, beginning with your current or most recent job. Include military service (indicate rank) and job related or volunteer work, if applicable. Indicate the number of employees supervised. Use a separate block to describe each position or gap in employment. ALL information in this section must be completed. Résumés may be attached to provide additional information. X Name of Present or Last Employer: _________________________________________________________________________ Address: ______________________________________________________________ Phone No.: (______) __________________ Your Job Title: ___________________________________________ Supervisor’s Name: _________________________________ From: _____/______/_____ To: _____/_____/_____ Hours Per Week: ________ No. Of Employees Supervised _______ Month Day Year Month Day Year Duties and Responsibilities: ___________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Reason for Leaving: __________________________________________________________________________ Y Previous Employer: _________________________________________________________________________ Address: ______________________________________________________________ Phone No.: (______) __________________ Your Job Title: ___________________________________________ Supervisor’s Name: _________________________________ From: _____/______/_____ To: _____/_____/_____ Hours Per Week: ________ No. Of Employees Supervised _______ Month Day Year Month Day Year Duties and Responsibilities: ___________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Reason for Leaving: __________________________________________________________________________ Z Previous Employer: _________________________________________________________________________ Address: ______________________________________________________________ Phone No.: (______) __________________ Your Job Title: ___________________________________________ Supervisor’s Name: _________________________________ From: _____/______/_____ To: _____/_____/_____ Hours Per Week: ________ No. Of Employees Supervised ______ Month Day Year Month Day Year Duties and Responsibilities: ___________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Reason for Leaving: __________________________________________________________________________ If needed, attach additional sheets, using the same format as on the application. Resumes may be attached to provide additional information. Government of the Virgin Islands – Employment Application [ Previous Employer: _____________________________________________________________________________________ Address: ______________________________________________________________ Phone No.: (______) __________________ Your Job Title: ___________________________________________ Supervisor’s Name: _________________________________ From: _____/______/_____ To: _____/_____/_____ Hours Per Week: ________ No. Of Employees Supervised _______ Month Day Year Month Day Year Duties and Responsibilities: ___________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Reason for Leaving: __________________________________________________________________________ \ Previous Employer: _________________________________________________________________________ Address: ______________________________________________________________ Phone No.: (______) __________________ Your Job Title: ___________________________________________ Supervisor’s Name: _________________________________ From: _____/______/_____ To: _____/_____/_____ Hours Per Week: ________ No. Of Employees Supervised _______ Month Day Year Month Day Year Duties and Responsibilities: ___________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Reason for Leaving: __________________________________________________________________________ ] Previous Employer: _________________________________________________________________________ Address: ______________________________________________________________ Phone No.: (______) __________________ Your Job Title: ___________________________________________ Supervisor’s Name: _________________________________ From: _____/______/_____ To: _____/_____/_____ Hours Per Week: ________ No. Of Employees Supervised ______ Month Day Year Month Day Year Duties and Responsibilities: ___________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Reason for Leaving: __________________________________________________________________________ If needed, attach additional sheets, using the same format as on the application. Resumes may be attached to provide additional information. Government of the Virgin Islands – Employment Application KNOWLEDGE / SKILLS / ABILITIES (KSAs) List KSAs you possess and believe relevant to the position you seek, such as computer skills, fluency in language(s), etc _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ BACKGROUND INFORMATION 1. Are you a U.S. Citizen or are you Legally Authorized to Work in the U.S.? YES NO 2. To your knowledge, do you have any relatives working in this agency? YES NO 3. Were you ever convicted of a sexually violent offense or sexual criminal offense against a minor? YES NO If, you answered “YES,” in accordance with Act # 6182, in order to attain employment, you must register with the Virgin Islands Department of Justice and give evidence of such registration. 4. Were you ever discharged or rejected during probation, or have you resigned YES NO under threat of discharge from any employment? If your answer is yes, please explain: _________________________________________________________________________ __________________________________________________________________________________________________________ 5. Have you ever been convicted of a felony or a first-degree misdemeanor? YES NO If your answer is “yes”, what charge? ________________________________________________________________________ Where convicted? ____________________________________________ Date of Conviction: ___________________________ 6. Have you ever pled no contest or pled guilty to a crime, which is a felony or a first-degree misdemeanor? YES NO If your answer is “yes”, what charge? ________________________________________________________________________ Where ______________________________________________ Date: ___________________________ VETERAN PREFERENCE INFORMATION 1. Do you claim veteran’s preference, if eligible? YES NO Check one: Veteran Widow or Widower of a Veteran Spouse of a 100% disabled veteran 2. Did you serve in active duty for the U. S. Military? YES NO 3. What was your discharge? Honorable or General Dishonorable Not Applicable 4. Do you have a service connected disability (rated 10% or more by V.A.)? YES NO (OPTIONAL) EEO SURVEY Date of Birth: _____________________ GENDER: MALE FEMALE RACE: (Check One): BLACK HISPANIC ASIAN or PACIFIC ISLANDER NATIVE AMERICAN WHITE OTHER (SPECIFY) _________________________________________________________________________________ CERTIFICATION I am aware that any omission, falsification, misstatement, or misrepresentations above may disqualify me for employment consideration and if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel staff, and other authorized employees of the Virgin Islands government for employment purposes. I understand and accept the fact that my consent shall remain effective during the tenure of my employment should I be hired. I understand that applications submitted for Government employment are public records. I certify that to be the best of my knowledge and belief all of the statements contained herein and on any attachment are true, correct, complete, and made in good faith. SIGNATURE: _________________________________________ DATE: ________________________ Revised 11-01-01