Transcription
STATE OF CONNECTICUTAPPLICATION FOR EMPLOYMENTCT-HR-12 Revised 12/06/2019Application for EmploymentInstructions to Applicant: Read the detailed instructions on the first page of this application and on theposition/job posting before completing this application form. Type or print answers to ALL questions.SECTION 1: Personal and Contact Information(Last Name)(First Name)(MI)(Address Number, Street, Apt.)(City, State, Zip)List other names you have used:(E-mail Address)(Primary Phone)(Alternate Phone )OK to leave message?(Extension)YesOK to leave message?NoYesNoSECTION 2: State Position/Job PostingJob Title: Job Posting Number:Location:SECTION 3: Applicant CertificationSIGNATURE REQUIRED: By signing or typing my name on the signature line below, I am certifyingthat the statements made by me on this application form and attachments, if any, are true andcomplete to the best of my knowledge and are made in good faith. I understand that if I make anymisstatement of fact, I am subject to disqualification and dismissal and to such other penalties as maybe prescribed by law or personnel regulations. All statements made on this application, includingemployment information, are subject to verification as a condition of employment.Applicant Signature:(Signature is required in order for your application to be considered)Note: A typed name will substitute for a handwritten signature.Date:
PAGE 2,Last NameFirst NameSECTION 4: Employment Preferences and Language FluencyI am a current State of CT employeeYou are required to select one of the following:I am a former State of CT employeeI have never been a State of CT employeeIf you are and/or were a State of CT employee, please enter your 6 digit employee ID number:Name of current agency and/or last agency employed:Are you lawfully permitted to work in the United States?YesNoIn which locations will you accept employment:All LocationsManchester-Howell CheneyAnsonia-Emmett O'BrienMeriden-H.C. WilcoxBridgeport-Bullard HavensMiddletown-VinalBristol-Bristol T.E.C.Milford-PlattDanbury-Henry AbbottNew Britain-E.C. GoodwinDanielson-H.H. EllisNorwich-NorwichGroton-E.T. GrassoStamford-J.M. WrightHamden-Eli WhitneyStratford-Stratford AviationHartford-A.I. PrinceTorrington-Oliver WolcottHartford-CT Aero TechWaterbury-W.F. KaynorWillimantic-WindhamAre you available for? Check all that are poraryInternshipPer DiemAvailable for shift preferences? Check all that are applicable:FirstSecondWeekendsAre you fluent in a language other than English? If required for the job for which you are applying:
PAGE 3,First NameLast NameSECTION 5: Education and TrainingIn order to receive educational credits toward qualification for the job posting, the institution must beaccredited.If the institution of higher learning is located outside of the United States, you are responsible for providingdocumentation from a recognized USA accrediting service which specializes in determining foreign educationequivalencies. The responsibility for and the costs associated with obtaining this equivalency information restwith the applicant. If applicable, please email the document to the Recruiter listed in the job opening.High School EducationDid you graduate from high school or receive a high school equivalency diploma (GED)?YesNoCollege and Graduate School Education1.(Name of School)(Street Address, City, State and Zip)Attended From: Attended To:(MM/YYYY)Degree Earned:Degree me of School)MasterDegree Earned:Degree me of School)MasterDegree Earned:Degree rateLawNone(Major and/or Minor)# of Credits Earned:DoctorateLawNone(Street Address, City, State, and Zip)Attended From: Attended To:(MM/YYYY)# of Credits Earned:(Street Address, City, State and Zip)Attended From: Attended To:(MM/YYYY)(Major and/or Minor)(Major and/or Minor)# of Credits Earned:MasterDoctorateLawNoneAttach additional sheets (labeled with “Section 5 – continued” and include your name in upperright corner) if you attended more than three (3) colleges/universities.
PAGE 4,First NameLast NameSECTION 5: Education and Training (continued)Specialized Training or Classes Relevant to Job1.(Name of School Attended)(City, State, Country)Attended From: Attended To:(MM/YYYY)2.(Name of School Attended)(MM/YYYY)(City, State, Country)Attended From: Attended To:(MM/YYYY)(Type of degree or certificate earned)(MM/YYYY)(Type of degree or certificate earned)SECTION 6: Licenses and Professional CertificatesEnter the required trade and professional licenses, certificates, or permits you possess applicablefor this job. (e.g. law, nursing, psychology, plumbing, teaching, coaching, educational etc.)1.Type: Number:Issued By: Date Issued: Expiration Date:(MM/DD/YY)2.Type: Number:Issued By: Date Issued: Expiration Date:(MM/DD/YY)3.(MM/DD/YY)(MM/DD/YY)Type: Number:Issued By: Date Issued:5.(MM/DD/YY)Type: Number:Issued By: Date Issued: Expiration Date:4.(MM/DD/YY)(MM/DD/YY)Expiration Date:(MM/DD/YY)YesDo you currently have a valid Motor Vehicle Driver's License (Class D)?NoList any endorsement(s) to your Class D license:6.Do you currently have a valid Commercial Driver's License (CDL)?CDL Class:Endorsement(s):YesNo
PAGE 5,First NameLast NameSECTION 7: Work Experience/Employment HistoryImportant Instructions Please list beginning with your most recent position, all of your work experience including military service and allvolunteer activities that you wish to be considered toward meeting the eligibility requirements (minimumqualifications) stated on the opening. Please do not submit a resume in lieu of completing this portion of the application. Be sure that the information included in this section demonstrates that you meet the experience qualifications for thejob for which you are applying. Failure to provide all of the REQUIRED information for each position may result in your application beingdisapproved. Although a resume may be attached, only jobs included in this section of the application form will be consideredwhen determining if you meet the required minimum qualifications for the position for which you are applying. Please make sure to list each position held, even with the same employer. If you need additional space for the descriptions of your duties for one or more positions, attach an 8 1/2” x 11” sheetwith your name and continue the descriptions of your duties, using the number sequence to identify which positionsthe duties belong to.JOB 1(Most Recent Job Title)Dates: From To(MM/YY)(MM/YY or Present)(Employer's Name)(Employer's Address)(Supervisor's Name)(Weekly Hours)Yes NoSupervise Others(Supervisor's Title)(Supervisor's Phone)(Number and Titles)YesNoMay We Contact EmployerReason for Leaving:Job Duties
PAGE 6,First NameLast NameSECTION 7: Work Experience/Employment History (continued)JOB 2(Job Title)Dates: From To(MM/YY)(MM/YY)(Employer's Name)(Employer's Address)(Supervisor's Name)(Weekly Hours)Yes(Supervisor's Title)(Supervisor's Phone)NoSupervise Others(Number and Titles)YesNoMay We Contact EmployerReason for Leaving:Job DutiesJOB 3(Job Title)Dates: From To(MM/YY)(MM/YY)(Employer's Address)(Employer's Name)(Supervisor's Name)(Weekly Hours)(Supervisor's Title)(Supervisor's Phone)Yes NoSupervise Others(Number and Titles)Yes NoMay We Contact EmployerReason for Leaving:Job Duties
PAGE 7,First NameLast NameSECTION 7: Work Experience/Employment History (continued)JOB 4(Job Title)Dates: From To(MM/YY)(MM/YY)(Employer's Name)(Employer's Address)(Supervisor's Name)(Weekly Hours)(Supervisor's Title)(Supervisor's Phone)Yes NoSupervise Others(Number and Titles)Yes NoMay We Contact EmployerReason for Leaving:Job DutiesJOB 5 Dates: From To(Job Title)(MM/YY)(Employer's Name)(Supervisor's Name)(Weekly Hours)(MM/YY)(Employer's Address)(Supervisor's Title)(Supervisor's Phone)Yes No(Number and Titles)Supervise OthersYes NoMay We Contact EmployerReason for Leaving:Job DutiesPAGE EIGHT
PAGE 8,First NameLast NameSECTION 8: Voluntary Equal Employment Opportunity InformationTo further its commitment to equal opportunity employment and meet State and Federal reportingrequirements, the State of Connecticut requests applicants to VOLUNTARILY provide the followinginformation. This information will be used for statistical purposes only by authorized personnel and will notbe considered in the evaluation of your application.A. GENDERFemaleMaleDecline to StateB. ETHNICITYHispanic or LatinoNot Hispanic or LatinoDecline to StateC. RACEPlease select from one of the followingAmerican Indian or Alaskan Native: Origins in any of the original peoples of North orSouth America, including Central America, and who maintains tribal affiliations orcommunity attachmentAsian: Origins in any of the original peoples of the Far East, Southeast Asia the Indiansubcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia,Pakistan, the Philippine Islands, Thailand and VietnamBlack/African American (Non Hispanic): Persons having origins in any of the black racialgroups of AfricaNative Hawaiian or Other Pacific Islander: Origins in the original peoples of Hawaii,Guam, Samoa, or other Pacific IslandsWHITE (Non Hispanic): Origins in any of the original peoples of Europe, the Middle East, orNorth AfricaTwo or more racesDecline to State
CT-HR-12 Revised 12/06/2019 SECTION 1: Personal and Contact Information . Stratford-Stratford Aviation Torrington-Oliver Wolcott Waterbury-W.F. Kaynor . College and Graduate School Education High School Education Did you graduate from high school or receive a high school equivalency diploma (GED)?
