BERKELEY COUNTY COMMISSION

400 W. STEPHEN STREET, Suite 201

MARTINSBURG, WV 25401
Fax: (304) 267-5049
Web Site: www.berkeleywv.org

EMPLOYMENT APPLICATION

INSTRUCTIONS: Applications are only accepted for posted positions. All applicants must provide a complete, separate and
signed application for each position.

(PLEASE PRINT OR TYPE) Date of Application:

POSITION APPLYING FOR:

NAME:
First Middle Last

ADDRESS:
Street City State Zip

CONTACT:
Home Phone Cell/Alternate Phone E-Mail Address

Do you feel that you can perform all the functions related to the job? Yes No
If not, specify:

Are you willing to take a physical examination? Yes No

Are you willing to undergo an alcohol and/or drug test? Yes No
Have you ever applied for employment with Berkeley County? Yes No
Date(s)
Have you ever been employed with Berkeley County? Yes No
If yes: Date(s): Department(s):
*
Drivers License Number Class Endorsement(s) State Exp. Date
*Do you currently have any active motor vehicle "points" on your driving record? Yes No
If Yes, how many points?
Are you legally authorized to work in the United States and willing to provide unexpired USCIS Form I-9
employment eligibility verification documentation upon request? Yes No

Do you have any relatives employed by Berkeley County Government? Yes No

Military Service
Branch of Service: Dates of Service From To

*This information must be disclosed ONLY if it is essential to the type of position you are applying for.
EDUCATION AND TRAINING
Do you have a high school diploma or GED? Yes No If not, what is the highest grade completed?
If you have a GED (High School Equivalency Diploma): Year Awarded State Awarded
Name, City & State of Last High School Attended:

COLLEGES ATTENDED DEGREE DATES ATTENDED

CITY & STATE MAJOR FIELD AWARDED FROM TO

OTHER TRAINING (including business, trade, military, etc.) TOTAL

HRS. WKS.
NAME OF SCHOOL CITY, STATE TYPE OF TRAINING

SPECIAL QUALIFICATIONS: (apprenticeships, skills, academic or professional awards, etc.)

OTHER QUALIFICATIONS: Data Entry or Key Boarding skills words per minute
Power Tools or Motor Equipment (list tools and equipment below)
Computer Skills (list specific hardware and/or software below)
Other (list below)

GENERAL INFORMATION
INSTRUCTIONS: The information listed below must be completed by all applicants. Failure to complete this information truthfully may
result in disqualification from consideration for County employment. Affirmative responses to these questions will not automatically
exclude you from employment consideration. Applicants may attach additional sheets if necessary:

1. If you have had disciplinary actions taken against you by any previous employer, please describe the facts and
circumstances.

2. Have you ever been discharged or asked to resign from any position for reasons other than disability?
Yes NO If yes, please explain.

3. Have you ever been convicted of a felony or crime of moral turpitude? ____ Yes ____ No

If yes, please explain ______________________________________________________

DATE: SIGNATURE OF APPLICANT:

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EMPLOYMENT HISTORY
Instructions: List below, beginning with your most recent position, all of your work experience, including military service assignments
and volunteer activities. Exclude organization names that indicate race, color, religion, sex or national origin. Please do not submit
a resume in lieu of completing this portion of the application.

Name of Employer: Employer’s Address (Street, City, State, Zip Code):

Type of Business: Supervisor’s Name and Phone Number:

Your Job Title: Do you supervise other employees? Job Titles of Those You Supervise:
Yes No
Dates of Employment (From: Month/Day/Year To: Month/Day/Year): Starting Salary: Ending Salary:

Job Duties:

Reason For Leaving:

Name of Employer: Employer’s Address (Street, City, State, Zip Code):

Type of Business: Supervisor’s Name and Phone Number:

Your Job Title: Did you supervise other employees? Job Titles of Those You Supervised:
Yes No
Dates of Employment (From: Month/Day/Year To: Month/Day/Year): Starting Salary: Ending Salary:

Job Duties:

Reason For Leaving:

Name of Employer: Employer’s Address (Street, City, State, Zip Code):

Type of Business: Supervisor’s Name and Phone Number:

Your Job Title: Did you supervise other employees? Job Titles of Those You Supervised:
Yes No
Dates of Employment (From: Month/Day/Year To: Month/Day/Year): Starting Salary: Ending Salary:

Job Duties:

Reason For Leaving:

Name of Employer: Employer’s Address (Street, City, State, Zip Code):

Type of Business: Supervisor’s Name and Phone Number:

Your Job Title: Did you supervise other employees? Job Titles of Those You Supervised:
Yes No
Dates of Employment (From: Month/Day/Year To: Month/Day/Year): Starting Salary: Ending Salary:

Job Duties:

Reason For Leaving:

All applicants must provide at least three (3) employment related references:
NAME TELEPHONE RELATIONSHIP
1.
2.
3.
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Instructions to applicant regarding form: Please sign form where requested and date it with the current date. Each employer
you listed under Employment History will be contacted and asked to answer the remaining questions.

REFERENCE SHEET

To Whom It May Concern:

The person named below has given your name as a past employer. Your response will be held in strict confidence.
Please return this form in the addressed envelope enclosed for you convenience.

Sincerely,

Gary Wine
County Administrator

I hereby authorize the organization listed below to disclose any requested information regarding my employment with said
organization to Berkeley County Commission and agree to release the organization and its agent from all liability as a result
of such a disclosure.
______________________________________________ ___________________
Applicant’s Signature Date

Name: ____________________________________________ Employed from _________ to ________

Company: _______________________________________________________________
Location of Employment: ____________________________________________________
____________________________________________________
Reason(s) for Leaving: ______________________________________________________
______________________________________________________
Eligible for Rehire? __________ Yes __________ No
Job Title: _____________________ _____________________________
Final Average Monthly Earnings: $ _____________________
Does this person have a history of work place violence? ________________________________________

________________________ __________________ ______________

Company Officer Title Date

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 PRE-EMPLOYMENT STATEMENT
READ CAREFULLY BEFORE SIGNING

I certify that the answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving
at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 180 days. Any applicant
wishing to be considered for employment beyond this time period should inquire as to whether or not applications are
being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship
with this organization is on an “at will” nature, which means that the Employee may resign at any time and the Employer
may discharge Employee at any time with or without cause. It is further understood that this “at will” employment
relationship may not be changed by any written document or by conduct unless change is specifically acknowledged in
writing by an authorized representative of the County Commission.

In the event of employment, I understand that false or misleading information given in my application or interview(s)
may result in discharge. I understand, also that I am required to abide by all rules of the employer.

Signature of Applicant Date

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 AFFIRMATIVE ACTION
FILLING OUT THIS FORM IS VOLUNTARY ON THE PART OF THE APPLICANT. THE INFORMATION ON THIS FORM WILL
HELP THE COUNTY COMMISSION TO ENSURE THERE IS NO DISCRIMINATION IN HIRING PRACTICES. THIS FORM
HAS BEEN ADDED TO THE APPLICATION IN COMPLIANCE WITH BERKELEY COUNTY’S AFFIRMATIVE ACTION POLICY.

GENDER: Male Female

RACE/ETHNIC IDENTIFICATION - PLEASE CHECK ALL THAT APPLY

Are you of Hispanic or Latino origin? Yes No
(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
Select one or more of the following racial categories:
American Indian or Alaskan Native (A person having origins in any of the original people of North or South America, including
Central America, and who maintains tribal affiliations or community attachment.)
Asian (A person having origin in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)
Black or African American (A person having origins in any of the black racial groups of Africa.)
Native Hawaiian or other Pacific Islander (A person having origins in the original peoples of Hawaii, Guam, Samoa, or other
Pacific Islands.)

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 FOR INTERNAL USE ONLY
Arrange Interview [ ] yes [ ] no
Remarks
__________________________________________________
___________
__________________________________________________
___________
Employed [ ] yes [ ] no Date of Employment ______
Job Title __________________ Hourly rate/salary _____
NOTES:
__________________________________________________
__________________________________________________
___________________________________