STATE OF ALABAMA DEPARTMENT OF VETERANS AFFAIRS 
ADVA Executive Administrator 
APPLICATION FOR EMPLOYMENT

"AN EQUAL OPPORTUNITY EMPLOYER"

A.	Applying for ADVA Executive Administrator position in Montgomery County.

Date

B.	Full name	Soc. Sec. #  	
First	Middle	Last

Current Address  					 Street or Route	City	State	Zip Code
Legal	Telephone # Home  	

Residence 	
County	State

Work  	

THE FOLLOWING IS REQUIRED FOR GOVERNMENTAL REPORTING AND RECORDKEEPING PURPOSES:

SEX (Check One)	RACE (Check One)

1|   | Male	1|

| White	3|

| Hispanic	5|

| American Indian/Alaskan Native

2|   |Female	2|   |Black	4|   |Asian/Pacific Islander	6| | Other

I am a registered voter in	County.

Do you have previous service with the State of Alabama? ( ) Yes (	) No If Yes, TRS ( ) ERS (	) Last Department/ Agency employed by and date of employment  		

I.	If you need special aids and/or services in order to accommodate a disability or health problem, (e.g., interpreters or reading devices), please indicate these requirements in the space below:

Have you ever been involuntarily terminated, discharged, forced or asked to resign, from any job or employment?
(	)Yes	(	)No	If you answered Yes to the above question, attach an explanation on a separate sheet noting any mitigating or extenuating circumstances.

NOTE: A CRIMINAL CONVICTION WILL NOT NECESSARILY BE A BAR TO CONSIDERATION FOR EMPLOYMENT. THE DISCLOSURE OF A MISDEMEANOR CONVICTION WILL NOT AUTOMATICALLY RESULT IN DISQUALIFICATION. CRIMINAL HISTORIES MAY BE SUBMITTED TO THE ALABAMA BUREAU OF INVESTIGATION FOR VERIFICATION. FAILURE TO DISCLOSE A CONVICTION MAY BE CONSIDERED AS GROUNDS FOR DISQUALIFICATION. FOR THESE REASONS, APPLICANTS SHOULD BE CAREFUL TO DISCLOSE ALL CRIMINAL CONVICTIONS IN THE SPACE BELOW:

II.	Have you even been convicted of a misdemeanor or criminal offense? (	)Yes	(	) No

If you answered Yes to the above question, list in the space below all prior misdemeanor and felony convictions and any extenuating or mitigating circumstances regarding such convictions. If necessary, you may use a separate sheet or sheets and attach to application.

C.	EDUCATION:
Highest grade completed:   	

Number of years college completed:  	

Special training:  	

Special skills relating to job sought:  	

D.	U. S. MILITARY SERVICE: 

Branch of Service: _____________________________ Were all discharges under honorable conditions? ( ) Yes ( ) No 

List all dates of active duty:

 		FROM 					TO 
______________________________________ _______________________________________ 
______________________________________ _______________________________________ 
______________________________________ _______________________________________

E.	List the name, address, and telephone numbers of 3 personal references other than your present employer:
Name	Address	Telephone Number

			

F.	Work History - This section must be completed regardless of whether or not a resume' is attached. (List last 3 employers, beginning with most recent):
Ending	Reason for
1.	Current Employer	From	To	Rate of Pay	Leaving
a.	 	

b.	Address and Phone No.   	

c.	Supervisor  	

Phone #  	
Ending	Reason for

2.	Previous Employer	From	To	Rate of Pay	Leaving
a.	 	

b.	Address and Phone No.  	

c.	Supervisor  	

Phone #  	
Ending	Reason for

3.	Previous Employer	From	To	Rate of Pay	Leaving
a.	 	

b.	Address and Phone No.  	

c.	Supervisor		Phone #  	

G.	I understand that any false, or misleading information furnished by me on this application form or in connection with my application for employment may result in rejection of the application.

Signature of Applicant

   Return completed application and Resume’ to:

Alabama State Department of Veterans Affairs 
Attn:  Rhonda Armstrong 
P O Box 1509
Montgomery, AL 36102-1509