Deputy Sheriff

DEPUTY SHERIFF

CIVIL SERVICE COMMISSION

COUNTY OF ROANE

ROANE COUNTYCOURTHOUSE

SPENCER, WEST VIRGINIA

FOR OFFICE USE ONLY
Accepted
Rejected
Examiner
Date of Notice
Grade
Rank

APPLICATION FOR EXAMINATION

______

Please complete using a typewriter or ink. Answer all questions as completely and accurately as possible – incomplete applications may be rejected or returned for corrections.

1. Position, grade or rank applied for: ______

2. Name: ______Sex: _____ SSN: ______

Last First Middle

3. Present Address: ______Phone No.______

Number and Street

______

City County State

4. Permanent address and legal residence: ______

(if different from above) Number and Street

______

City County State

5. Marital Status: _____Married ______Divorced ______Single

6. Height:______Weight:______Age:______Date of Birth:______

7. Place of Birth: ______

8. Are you a U.S. Citizen? ____Yes _____No

If naturalized citizen, give the date and place: ______

9. List names, age, sex and relationship of all dependants:

______

______

______

______

______

10. How long have you been a resident of the State of West Virginia? ______

List your residences of the last three years:

______

______

______

11. Do you have any physical defects, chronic illnesses or physical impairments? ___Yes ___No

If yes, please explain:

______

12. Are you willing to submit to a physical examination? ____Yes ____No

13. EDUCATION: Part A

TYPE / YEARS / NAME AND LOCATION of SCHOOL / DATES FROM/TO / DEGREE
Elementary / 5 6 7 8
High School / 1 2 3 4
1 2 3 4
1 2 3 4
College / 1 2 3 4
1 2 3 4
1 2 3 4
Post Graduate
Studies / 1 2 3 4
1 2 3 4
Professional / 1 2 3 4
1 2 3 4
Vocational or
Business / 1 2 3 4
1 2 3 4

EDUCATION: Part B

In the space provided, list any additional training (i.e. correspondence courses, apprenticeships, etc.) you have received.

______

______

______

In the space below, list any scholastic honors, affiliations with professional societies, etc.

______

______

______

In the space below, list any special qualifications (i.e. knowledge of law, mechanical arts, reading, writing or speaking knowledge of foreign languages, etc.) not covered in the preceding questions.

______

______

______

14: EMPLOYMENT: Part A

Please start with current employer and work backward. List all principal work. Note any temporary or part-time work as such. Attach separate sheet if needed.

DATES
FROM/TO / EMPLOYER’S NAME AND ADDRESS / DUTIES / REASON FOR
LEAVING

EMPLOYMENT: Part B

List the names of any specific courses you have had which may pertain to the position for which you are applying:

______

______

______

______

______

______

If you have had fewer than three (3) employers, please list the names and addresses of three (3) persons not related to you who know your qualifications.

NAME / ADDRESS / VOCATION

15. Have you previously filed an application with this department? ____Yes ____No

If yes, please give date and position applied for: ______

16. Would you accept part-time employment? ____Yes ____No

17. If employed, how soon could you report for work? ______

18. Have you ever been arrested, indicted, or convicted for violation of any law other than minor traffic regulations? ____Yes ____No

If yes, please explain in detail: ______

______

______

______

19. VERIFICATION AND CERTIFICATION (All applicants must sign the following certificate)

I hereby certify that there are no willful misrepresentations in and falsifications of the above statements and answers to questions. I am aware that should an investigation disclose such misrepresentations and falsifications, my application will be rejected and I will be disqualified from applying in the future for any position under the jurisdiction of the Civil Service Commission for RoaneCounty.

(Signature of Applicant)______

(Date)______

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