OPENING DATE: October 17, 2017 CLOSING DATE: October 31, 2017 LOCATION: Base Civil Engineering, 130 th Airlift Wing, Charleston, West Virginia

Similar documents
OPENING DATE: 10 August 2017 CLOSING 8 September 2017 LOCATION: Base Civil Engineering, 130 th Airlift Wing, Charleston, West Virginia

APPLICATION FOR EMPLOYMENT

Education and Training

APPLICATION FOR EMPLOYMENT EASTERN SHORE RURAL HEALTH SYSTEM, INC, Market Street, Onancock, VA 23417

2. Use the space bar or the mouse to check the appropriate boxes.

Columbia College Director of Teacher Education and Accreditation

CITY OF HOLLY HILL EMPLOYMENT APPLICATION 1065 Ridgewood Avenue Holly Hill, Florida An Equal Opportunity Employer

WAKULLA COUNTY. EMPLOYMENT APPLICATION Equal Opportunity Employer/Affirmative Action Employer EDUCATION HIGH SCHOOL: POSITION APPLIED FOR.

APPLICATION FOR EMPLOYMENT

Thank you for your interest in employment with Black Hills Surgical Hospital and Black Hills Urgent Care.

ALAMEDA COUNTY EMPLOYMENT APPLICATION

AVI Systems, Inc. Employment Application

Title: Date Available:

APPLICATION FOR EMPLOYMENT

Applicant Information

APPLICATION FOR EMPLOYMENT

Employee EEO Self-Identification Form

Name: First Middle Initial Last Social Security Number: Current Street Address/Apt #: City: State: Zip Code:

(City) (State) (Zip Code) (Evening) Are you legally authorized to work in the United States? Yes. No If yes, who? EMPLOYMENT DESIRED

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

Crothall Services Group Environmental Services / Housekeeping

Juvenile Services Officer Application Information

Equal Employment Opportunity Self-Identification Applicant Survey

Equal Employment Opportunity Self-Identification Applicant Survey

AMERICAN AMBULANCE SERVICE, INC.

FIRE RECRUIT CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS MINIMUM QUALIFICATIONS

TEMPORARY LECTURER APPLICATION FOR EMPLOYMENT

EQUAL EMPLOYMENT OPPORTUNITY DATA FORM Please Return to: City of Geneva Human Resources 22 South First Street Geneva, IL 60134

16 th Annual Nurse Camp Application Packet Checklist


EMPLOYMENT APPLICATION Part 1. Please answer all questions completely and print legibly.

CODAC BEHAVIORAL HEALTH SERVICES, INC.

Part Time Student Office Clerk Administrative Services Support Team Job Responsibilities

Volunteer Application

Employment Application

Additionally, the parent or legal guardian must provide the following documents upon registration of a new student:

Position Title: Pediatric Nurse Practitioner-Lafayette, IN. Status: Full-Time

St. Mary s County Health Department

Cahokia Volunteer Fire Department. Application for Membership

Example Application DO NOT SUBMIT

Complete the Attached Addendum


EMPLOYMENT PRE-SCREEN QUESTIONNAIRE

EMPLOYMENT PRE-SCREEN QUESTIONNAIRE

Ethnic Minorities and Women s Internship Grant Guidelines

Volunteer Fire Department 2358 Bradway Road North Pole, Alaska (907) Steven H. Crouch-Fire Chief. 24 Hour Firefighter

CITY OF NEW BEDFORD APPLICATION FOR EMPLOYMENT PERSONNEL DEPARTMENT 133 WILLIAM STREET, ROOM 212 NEW BEDFORD, MA (508)

Firefighter Application Packet City of Texarkana, Texas

GENERAL APPLICATION FOR EMPLOYMENT

Durham, New Hampshire 03824

Employment is contingent upon completing a six (6) month probationary period.

Washington County Tennessee Sheriff s Office. Ed Graybeal, Sheriff. Employment Application Packet

Volunteer Fire Department Member Application

EMPLOYMENT APPLICATION

Prequalification Questionnaire Vendor / Contractor/ Consultant

Candidates failing to include ALL required documentation will be disqualified.

An Equal Opportunity Employer

Name: The Town of East Haven. Application for Employment. Position: Secretary II, Grade Level 10

City of Patterson Employment Opportunity FIREFIGHTER-PARAMEDIC

CITY OF DOVER POLICE DEPARTMENT APPLICATION FOR POLICE OFFICER

Deputy Sheriff Trainee (Sponsorship)

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Subsurface Sewage Disposal System INSTALLER License Application

EMPLOYMENT APPLICATION

NASA Ames Research Center Fire Department

New Substitute Paraprofessional or Secretary Fingerprint-Based Criminal Background Check Procedures

~ PARTICIPANT APPLICATION ~

CITY OF TWIN FALLS JOB ANNOUNCEMENT

EMPLOYMENT APPLICATION & INSTRUCTIONS

APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

WEST HAVEN FIRE DEPARTMENT 366 Elm Street, P.O. Box 207 West Haven, Connecticut (203) Fax (203)

Employment Application

2015/2016 PLUMBERS & PIPEFITTERS LOCAL 502 APPRENTICESHIP PROGRAM

F I R E F I G H T E R Salary: $4,152 - $5,344 monthly / Grade F11 Filing Deadline: 5:00 pm, Thursday, June 28, 2018

NASA Ames Research Center Fire Department

Peoria Heights Fire Department. Membership Application Packet

GENERAL APPLICATION FOR EMPLOYMENT Human Resources City of New Smyrna Beach 210 Sams Avenue New Smyrna Beach, Florida 32168

AMHERST COUNTY SHERIFF'S OFFICE An equal opportunity employer Women and Minorities are encouraged to apply.

Danville Fire Department. Application Packet. Full-Time Paramedic / Firefighter

Applications accepted for available positions ONLY

Application for Employment An Equal Opportunity / Affirmative Action Employer

UNITED STATES ARMY INTELLIGENCE AND SECURITY COMMAND

WHITMAN COUNTY CIVIL SERVICE COMMISSION

Sentinel Transportation, LLC

VERMILLION COUNTY SHERIFF'S OFFICE

Fire & Rescue. Application & Information Packet

CURRENT RATE OF PAY: $10.85/HR

Crandall Fire Department

An Equal Opportunity/ADA Compliant Employer. COMPENSATION $5, $6, Monthly

CITY OF PLANT CITY 302 W. REYNOLDS STREET P. O. BOX C PLANT CITY, FLORIDA PHONE (813)

Job Classification: FIREFIGHTER RECRUIT & EMCT - EMT/EMCT - Paramedic

Please print clearly as you fill out the application. Social Security #: Are you known by other names while previously employed?

Kaiser Permanente Youth Exploration Academy in Healthcare (KP YEAH!)

DEPUTY CHIEF HUNTLEY FIRE PROTECTION DISTRICT CORAL AVENUE HUNTLEY, ILLINOIS PHONE: (847)

DANE COUNTY PUBLIC SAFETY COMMUNICATIONS

CIVIL SERVICE COMMISSION CITY OF TYLER, TEXAS. Announces an Examination for FIRE RECRUIT

THE CITY OF TRAVERSE CITY. is recruiting for: Fire Fighter/Paramedic Traverse City Fire Department (24-hour shifts)

UNITED STATES ARMY INTELLIGENCE AND SECURITY COMMAND

UNITED STATES ARMY INTELLIGENCE AND SECURITY COMMAND **APPLICATIONS WILL ONLY BE ACCEPTED DURING THE CAREER FAIR**

Transcription:

RWEST VIRGINIA MILITARY AUTHORITY 1703 COONSKIN DRVIE CHARLESTON, WEST VIRGINIA 25311-1085 O&M AGREEMENT POSITION VACANCY ANNOUNCEMENT ANNOUNCEMENT NUMBER: WVMA-ML171002 OPENING DATE: October 17, 2017 CLOSING DATE: October 31, 2017 LOCATION: Base Civil Engineering, 130 th Airlift Wing, Charleston, West Virginia JOB TITLE: Probationary Firefighter: This (Recruitment) will be used to establish a list of qualified candidates to fill the current vacancy and may be used to fill future vacancies as they occur over a fifteen month period. SALARY: Probationary Firefighter (3E731/51) Range $36,060 -$-$54,180 ANNUALLY MILITARY MEMBERSHIP: Position will be filled by a member of the West Virginia National Guard assigned to Fire Emergency Services; the individual must be/or become a member as condition of employment.xc GENERAL DESCRIPTION OF WORK: Individual performs firefighting, rescue, salvage, fire prevention and other fire protection operations for the protection operations of base facilities, equipment and personnel. MINIMUM MANDATORY CERTIFICATIONS: Fire fighter (AFSC 3E731/51: Required DOD Certification [Fire Fighter II, Airport Fire Fighter, HAZMAT Operations. HOW TO APPLY: Anyone interested in applying for this position must submit a completed State of West Virginia Application for Employment, resume and copies of required certifications to: West Virginia Military Authority, Attn. HR Employment Application, 1703 Coonskin Drive, Charleston, WV 25311 or you may fax to 304-561-6321 or email to deborah.s.taylor28.nfg@mail.mil All applications must be received by closing date. Applications may be obtained from the WVNG HRO web site: http://www.wv.ngb.army.mil/jobs/forms/default.html. SPECIAL REQUIREMENTS: 1. POSITION TO BE FILLED UPON AVAILABILITY OF RESOURCES. 2. POSITION IS CONTINGENT UPON RECEIPT OF CONTINUED DEPARTMENT OF DEFENSE FUNDING. 3. THIS POSITION FALLS UNDER THE WEST VIRGINIA PUBLIC EMPLOYEES RETIREMENT SYSTEM (PERS). 4. CONSIDERATION WILL BE GIVEN TO ALL QUALIFIED APPLICANTS WITHOUT REGARD TO RACE, COLOR, RELIGION, SEX, NATIONAL ORIGIN, POLITICS, AGE, MEMBERSHIP OR NON-MEMBERSHIP IN AN EMPLOYEE ORGANIZATION. 5. STATE POSITIONS ANNOUNCED BY THE ADJUTANT GENERAL ARE AT-WILL EMPLOYMENT POSITIONS. THE TERM AT-WILL EMPLOYMENT MEANS THAT THE EMPLOYEE MAY BE TERMINATED AT ANY TIME WITHOUT CAUSE. 6. EMPLOYMENT SUBJECT TO FAVORABLE SECURITY AND BACKGROUND CHECK.

TITLE: PROBATIONARY FIREFIGHTER PAY GRADE: TBD I. OCCUPATIONAL REQUIREMENTS: Incumbent subject to uncommon tours of duty, rotational shift assignments. May be required to fly in military or civilian aircraft for TDY purposes. May be required to respond to requests for support from civilian fire departments. II. III. IV. INTRODUCTION: This position exists to provide fire protection and related services to personnel and resources of the West Virginia Air National Guard, Yeager Airport Charleston, WV. Position is 100% federally funded and is considered mission essential. Due to the repetitive nature of normal duties, not knowing when emergency situations will arise, normal duties may not be completed at normally scheduled times. They are to be completed by 1600 hours of that duty day unless otherwise approved by the Assistant Fire Chief. Firefighters receive recurring proficiency training as directed by AFMAN 32-2003 and AFI 32-2001/ANG Supp. 1. Various training aids and manuals give firefighters adequate training. Work assignments are made on crew basis in rotation. Normal assignments are completed by the day of week, i.e., Monday-clean vehicles, Tuesday-bunkroom, etc. The following duties, responsibilities and requirements constitute minimum requirements for this position. DUTIES AND RESPONSIBILITIES: Works scheduled 24-hour shifts in a variety of duties at the fire station and at the scene of an aircraft crash, fire or other emergency. a. Reports directly to the Crew Chief, Assistant Chief and/or Fire Chief. b. Performs inspection and operator maintenance of firefighting vehicles, tools, equipment, protective clothing, and maintains station facilities in a safe, efficient and timely manner following prescribed procedures. Missed scheduled maintenance and inspection procedures could affect performance rating negatively. c. Drives and operates crash/fire rescue vehicles. Operates tools and equipment, controls and extinguishes aerospace vehicle fires. Performs overhaul and salvage operations, airfield patrol surveillance, standbys and fuel spill cleanup. Assists in evacuation of personnel from buildings, protects exposures and positions and operates tools and equipment. Controls and extinguishes structural fires, loads hose and hose load finishes. d. Perform building inspections and pre-fire planning; perform maintenance and testing of all building Fire alarm systems, wet and dry pipe sprinkler systems, deluge systems and any other firefighting systems. These duties will be performed IAW prescribed regulations and procedures. Failure to perform the above will reflect negatively on performance evaluation. e. Effects entry by normal and emergency means in aircraft and buildings, shuts down aircraft engines and systems, performs rescue and administers emergency first aid and CPR if necessary. These duties will be performed efficiently and safely as possible. Failure to perform the above duties is considered unsatisfactory and will affect the performance rating negatively. f. Participates in all training, classroom and practical, IAW current regulations and directives, and assists in evaluating training done by other firefighters. More than six missed training classes and/or drills will be considered unsatisfactory and will affect performance rating negatively. g. Performs fire alarm and communications center duties. Alerts firefighting personnel and support agencies, dispatches equipment, and inform personnel of location and nature of fires. Directs all incoming calls to appropriate personnel and takes messages. Will operate alarm room IAW AFI 32-2001/ANG Supp.1. Noncompliance with AFI 32-2001/ANG Supp. 1 will affect performance rating negatively.

h. Strictly adhere to policies and regulations IAW the operating instructions of this Fire Department, The State of West Virginia regulations and AFI 32-2001/ANG Supp. 1. Will conduct himself or herself in a professional manner at all times and maintain the proper attitude toward the position at all times. Will be on time for all shifts unless leave has been approved or the Assistant Fire Chief has approved the individual being late. Being late for roll call more than twice without approval during the rating period will be considered unsatisfactory and will affect the performance rating negatively. i. Must acquire a working knowledge of regulations, directives, operating instructions and standards. j. Must acquire a working knowledge of all mission related hazardous materials. k. Must be able to make immediate decisions during emergency situations. l. Other duties as assigned. V. SUPERVISORY CONTROLS: Reports to the Crew Chief or Assistant Chief for crew assignments. VI. QUALIFICATIONS: a. AGE REQUIREMENT: 1. Candidates must be at least age 18 at the time of this announcement. 2. Maximum age of 39 at the time of probationary appointment. (Industry standard is usually 37) due to retirement qualifications. b. MANDATORY: 1. Must have at least one year experience with military or organized civilian fire department. ANG/CEXF requires the following certifications: IFSAC or DoD certifications for Firefighter II, Airport Firefighter and HazMat Operations. With a knowledge of characteristics, range, and effectiveness of various extinguishing agents, combustible materials, fire alarm systems, first aid, firefighting apparatus and allied equipment, firefighting and rescue techniques, and other operations peculiar to crash/fire rescue. Must be/or must complete a State and National EMT-B course within 36 months of appointment and maintain then for continued employment. 2. Must submit to and pass, without exception, initial and annual occupational physicals in accordance with the current edition of NFPA 1582 (Medical Requirements for Firefighters). 3. Candidates will receive Psychological evaluations in accordance with the current edition of NFPA 1582 (Medical Requirements for Firefighters). 4. High school diploma or GED equivalent. 5. Qualified personnel are hired in accordance with department needs, State and Federal policy and Affirmative Action Plan. 6. Objectives are met on schedule and special projects are completed as required. 7. Must possess and maintain, at all times, a state and government vehicle operator s license. Failure to do so could result in dismissal. 8. Must have a working knowledge of all assigned firefighting and rescue equipment.

9. Must be familiar with egress and safety procedures of all assigned military and civilian aircraft. 10. Must be knowledgeable in operation of vehicles and radios around aircraft movement areas. 11. Must be willing to be tested for communicable diseases and illegal substance consumption. Positive results will result in instant dismissal. 12. 12 month probationary period. 13. Must complete all required training, to obtain skill level 3E751, i.e. (CDC, or in residence). Within 12 months of appointment. 14. Must be/or must complete a State and National EMT-B course within 36 months of appointment and maintain then for continued employment. 15. Be a member of the WVANG Assigned to the Fire Emergency Services career field. c. OCCUPATIONAL ASSESSMENT: CARDIOVASCULAR ASSESSMENT 1. 1.5 mile run required to be completed within 13:00 minutes. OCCUPATIONAL ASSESSMENT The assessment component requires firefighters to complete ten simulated firefighting tasks on obstacle course (circuit) wearing Fitness Clothing with a 50 pound weight vest. In a consecutive manner without stopping. The ten tasks are as follows: Task 1: One Arm Hose Carry. Carry one 50-ft section of 3-inch hose 100 feet. Task 2: Ladder Raise. Carry a 12-ft ladder 50 feet and raise it against a wall Task 3: Charged Hose Drag. Drag a charged 1.5-1 ¾ inch hose 100 feet. Task 4: First Ladder Climb. Climb a 24-ft ladder (10 rungs) three times. Task 5: High Volume Hose Pull. Pull a section of 4.5 or 5-inch hose 100 feet hand over hand. Task 6: Forcible Entry. Move a 225lb tire 12 inches using a 10-lb Sledgehammer. Task 7: Victim Drag. Drag a mannequin weighing 150 pounds 100 feet. Task 8: Second Ladder Climb. Climb a 24-ft ladder (10 rungs) twice. Task 9: Ladder Lower. Lower a 12-ft ladder and carry it a distance of 50 feet. Task 10: Spreader Tool Carry. Carry an 80-lb spreader tool (Hurst Tool) 100 feet. d. DESIRABLE: 1. Completion of a U.S. Air Force Fire Protection Course and have attained the U.S. Air Force AFSC or equivalent. 2. Advanced training in the various facets of firefighting from a qualified IFSAC accredited school.

West Virginia Military Authority APPLICATION FOR EMPLOYMENT 1703 Coonskin Drive Cha rleston, West Virginia 25311 PH: 304-561-6314 JOB CLASSES FOR WHICH YOU ARE APPLYING Application cannot be processed without at least one job title 1. 2. 3. Announcement Number 1. 2. 3. SOCIAL SECURITY NUMBER (See SSN note in instructions) LAST NAME FIRST NAME MIDDLE INITIAL STREET ADDRESS CITY, STATE, and ZIP COUNTY OF RESIDENCE HOME PHONE CELL PHONE MARK ALL EMPLOYMENT TYPES YOU WILL ACCEPT A Permanent Full-Time B Permanent Part-Time C Temporary Part-Time D Intermittent E Intern MARK ALL SHIFTS YOU WILL ACCEPT A Day Shift B Evening Shift C Night Shift D Rotating Shift DATE AVAILABLE TO BEGIN WORK EMAIL ANSWER EACH OF THE FOLLOWING May we contact you via email? Have you applied to the Military Authority in the last 12 months? Y N Have you applied to the Military Authority using a different full or last name? If yes, enter other name. Have you previously held or do you currently hold a job covered by the Military Authority? Can you legally work in the U.S.? If temporarily, enter expiration date. Have you been convicted of a felony in the past seven years? Yes No NOTE: A yes answer will not cause your name to be removed from an employment register or bar you from all employment unless the conviction relates to the position for which you are applying. MILITARY SERVICE and VETERANS PREFERENCE POINTS: Completion of this section is voluntary; however you must do s e ee s eee e s e s e e e score for any person who meets the eligibility requirements. Five additional Five (5) points shall be added to e points may be awarded if you received a Purple Heart Award or if you have a verified compensable service-connected disability. Before completing this section, please read the Veterans Preference Eligibility Require-ments information in the applications instructions. Yes No Are you claiming five Veterans Preference Points for service in the United States Armed Forces? Are you claiming an additional five Veterans Preference Points based on: : Yes No A Purple Heart Award? (If yes, the award must be stated on the DD214 Form).) Yes No A verified compensable service-connected disability? (If yes, a Veterans Administration letter dated within the past six months is required see instructions) 1

West Virginia Military Authority EMPLOYMENT HISTORY: List all work experience beginning with your present/most recent employer and work back. Changes in title, duties, or employment status with the same employer must be listed as separate jobs. Be sure to show employment dates and hours worked per week, and for paid work, you must list a salary. If more space is needed to describe your duties, feel free to attach additional pages. For more on this section, refer to the instruction pages. IMPORTANT: Resumés may be submitted in addition to the information provided on these pages. EMPLOYER NAME EMPLOYER ADDRESS EMPLOYER PHONE BUSINESS TYPE SUPERVISOR S NAME YOUR JOB TITLE LAST SALARY EMPLOYMENT DATES (month/year) From To EMPLOYMENT STATUS HOURS WORKED Paid Volunteer Full-Time Part-Time Hours Worked Per Week SUPERVISORY EXPERIENCE Did you supervise employees? Yes No Date you began supervising (month/year) List title(s) and number(s) of employees you officially supervised DETAILED DESCRIPTION OF YOUR JOB DUTIES EMPLOYER NAME EMPLOYER ADDRESS EMPLOYER PHONE BUSINESS TYPE SUPERVISOR S NAME YOUR JOB TITLE LAST SALARY EMPLOYMENT DATES (month/year) From To EMPLOYMENT STATUS HOURS WORKED Paid Volunteer Full-Time Part-Time Hours Worked Per Week SUPERVISORY EXPERIENCE Did you supervise employees? Yes No Date you began supervising (month/year) List title(s) and number(s) of employees you officially supervised DETAILED DESCRIPTION OF YOUR JOB DUTIES 2

West Virginia Military Authority EMPLOYMENT HISTORY: List all work experience beginning with your present/most recent employer and work back. Changes in title, duties, or employment status with the same employer must be listed as separate jobs. Be sure to show employment dates and hours worked per week, and for paid work, you must list a salary. If more space is needed to describe your duties, feel free to attach additional pages. For more on this section, refer to the instruction pages. IMPORTANT: Resumés may be submitted in addition to the information provided on these pages. EMPLOYER NAME EMPLOYER ADDRESS EMPLOYER PHONE BUSINESS TYPE SUPERVISOR S NAME YOUR JOB TITLE LAST SALARY EMPLOYMENT DATES (month/year) From To EMPLOYMENT STATUS HOURS WORKED Paid Volunteer Full-Time Part-Time Hours Worked Per Week SUPERVISORY EXPERIENCE Did you supervise employees? Yes No Date you began supervising (month/year) List title(s) and number(s) of employees you officially supervised DETAILED DESCRIPTION OF YOUR JOB DUTIES EMPLOYER NAME EMPLOYER ADDRESS EMPLOYER PHONE BUSINESS TYPE SUPERVISOR S NAME YOUR JOB TITLE LAST SALARY EMPLOYMENT DATES (month/year) From To EMPLOYMENT STATUS HOURS WORKED Paid Volunteer Full-Time Part-Time Hours Worked Per Week SUPERVISORY EXPERIENCE Did you supervise employees? Yes No Date you began supervising (month/year) List title(s) and number(s) of employees you officially supervised DETAILED DESCRIPTION OF YOUR JOB DUTIES 3

West Virginia Military Authority EDUCATION: If you need additional space, provide the information on a separate sheet of paper. Did you receive a high school diploma or GED equivalent? High School Diploma GED Equivalent Neither Mark highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12 Additional Education: All academic training other than High School/GED Equivalent must be verified. Verification of academic training may be in the form of an official transcript, copy of diploma or certificate, or written statement from an authorized agency verifying possession of the necessary credentials. SCHOOL NAME and ADDRESS FIELD(S) of STUDY CREDIT HOURS ATTENDANCE DATES major minor sem. qtr. mo./yr. mo./yr. TYPE OF DEGREE ATTACH TRANSCRIPT BUSINESS/VOCATIONAL/ TECHNICAL SCHOOL COURSE(S) of STUDY NO. WEEKS ATTENDED HOURS PER DAY CLOCK HRS. COMPLETED CERTIFICATE ATTACH COPY I would submit to drug testing if required. Yes No REFERENCES: Please provide three personal references that we may contact. NAME ADDRESS PHONE Do you have family members/relatives that are currently employed by the West Virginia Military Authority or the West Virginia National Guard? Yes No If yes, please list their names in the box below. AFFIRMATION: I certify under penalty of law and disqualification that all statements are true and complete. I authorize the State of West Virginia and any agent acting on its behalf to conduct an inquiry into any job-related information contained in this application. I release the State of West Virginia and any agent acting on its behalf from any and all liability by reason of the request for such information. I further authorize and request each former employer educational institution, or organization (including law enforcement agencies) to provide all information that may be sought in connection with this application. Yes No If you are a male, age 18-25, have you registered, as required, with the U.S. Selective Service? SIGNATURE: DATE: 4

West Virginia Military Authority OPTIONAL EQUAL EMPLOYMENT OPPORTUNITY QUESTIONNAIRE The following information will be used solely to evaluate recruitment and examination methods. This form will be kept separate from your application and will not be shared with hiring agencies. Nothing you write on this form will in any way affect your test score or your chances for employment. Answering these questions is voluntary; however, your cooperation is essential for us to ensure equal employment opportunity for all job applicants. Enter the information below as indicated. Please enter only one number or mark per block do not use dashes or other punctuation or symbols. SOCIAL SECURITY NUMBER DATE of BIRTH GENDER only one number per block EX: June 25, 1977 would be 0 6 2 5 7 7 MALE FEMALE GGGGGGGGG GG GG GG G G DISABILITY INFORMATION: A disabled individual is any person who: has a disability which substantially limits one or more of the major life activities, has a record of such impairment, and/or is regarded as having such an impairment. Yes No Do you have a qualifying disability? RACIAL/ETHNIC BACKGROUND: Please mark the item which best describes your PRIMARY racial/ethnic background. Mark only one item. BLACK A person having origins in one of the black racial groups of Africa. HISPANIC A person of Mexican, Puerto Rican, Cuban, Central American, South American, or other Spanish culture or origin, regardless of race. WHITE A person having origins in any of the original people of Europe, North Africa, or the Middle East. AMERICAN INDIAN or ALASKAN NATIVE A person having origins in any of the original people of North America and who maintains cultural identification through tribal affiliation or community recognition. ASIAN or PACIFIC ISLANDER A person having origins in any of the original people of the Far East, Southeast Asia, the Indian subcontinent, or any of the Pacific Islands. Some examples include China, India, Japan, Korea, the Philippine Islands, Pakistan, Vietnam, Hawaii, Guam, and Samoa. SOURCE(S) of INFORMATION: Mark up to four sources of information below in rank of importance. Mark your most important sources with a 1, your second most important sources with a 2, and so on. Rank at least one source, but not more than four. G G G A) DOP Counselor E) Div. of Human Services I) Radio Announcement G G B) DOP Information F) High School Counselor Booklet G or Teacher G G J) Newpaper C) DOP Recruiter G) College Placement G Information G Office or Advisor G G K) Friend/Neighbor D) WorkForce WV H) State Vocational G or Job Serv. Off. G Rehabilitation Office G G L) State Employee M) State Agency Referral N) DOP Website Information O) Other (explain) P) Other (explain) 5