Government of the



Return ALL applications and support documents to:



United States Virgin Islands



Employment Application



An Equal Opportunity Employer



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GERS Bldg., 3 Floor Xt 48B-50C Kronprindsens Gade Xf St. Thomas, U.S.V.1. 00802 *¢ (340) 774-8588 xt Fax (340) 714-5040

Orange Grove Shopping Center Xt Bays #6,7, & 8 Xt Christiansted, St. Croix, U.S. V.I 00820 (340) 773-0341 <4 Fax (340).773-5669



GENERAL INSTRUCTIONS



Type or print clearly in ink this application in its entirety.



e Specify the position for which you are applying.



Applications will be processed ONLY for vacant positions.



e Your application and accompanying (birth certificate, social

security card, educational documents, proof of citizenship,

training certificates, resume, photo ID, DD 214) maicerials

are confidential and become the property of the Division of

Personnel for the Government of the Virgin Islands.



e Applications that are received unsigned will not be processed

and all information you submit is subject to verification.



e Applications are valid for one (1) year from date of receipt

and must be upgraded on a yearly basis.



e Resumes will not be accepted in lieu of completing application



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CIst. Thomas CJ St. Croix CO St. John



POSITION (S) APPLIED FOR:



HOW DO WE CONTACT YOU:



First Name MI. Last Name

Social Security Number

Mailing Address

Physical Address

City State Zip Code

Home Phone Business Phone Cellular Phone

E-Mail Address



= EDUCATION. ae ae

High School, College, University or Professional School: (An Official Transcript may be required)

Attontance Credit Hours Type of

Name of School Location (Month/Year) Earned Course of Study Degree

From To Qtr | Sem.



- JOB RELATED TRAINING AND COURSE WORK:



Vocational, Trade, Government, Business, Armed Forces, etc.



as OF Credit Hours Training

. 5 9

Name of School Location (Month/Year) Earned Course of Study Completed?

From To | Class | Clock YES | NO

. YW [yA 8 ° A ¢ A is 8, b DA Pa

License, Registration or Certification Number Date Received Expiration Date



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? oO YES C] NO

3. Were you ever convicted of a sexually violent offense or sexual criminal offense against a minor? CL] YESE] 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 [j] NO

_ under threat of discharge from any employment?



If your answer is yes, please explain:

5. Have you ever been convicted ofa felony or a first-degree misdemeanor? L] 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 [CL] NO



If your answer is “yes”, what charge?



Where Date:



VETERAN PREFERENCE INFORMATION



1. Do you claim veteran’s preference, if eligible? [] YES LJ] 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? Cj] YES [-] NO

What was your discharge? C] Honorable or General {| Dishonorable [[] Not Applicable



4. Do you have a service connected disability (rated 10% or more by V.A.)? Cy YES [] NO

(OPTIONAL) EEO SURVEY



Date of Birth: GENDER: [] MALE []_ FEMALE



RACE: (Check One):

[] BLACK [ HISPANIC [] ASIAN or PACIFIC ISLANDER [] NATIVE AMERICAN[] WHITE

[1 OTHER (SPECIFY)



Iam aware that any omission, falsification, misstatement, or misrepresentations above may disqualify me for employment consideration and if]

am hired, may be grounds for termination at a later date. 1 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