Cms 100 Application – Fill Out and Use This PDF

STATE OF ILLINOIS

DEPARTMENT OF CENTRAL

MANAGEMENT SERVICES

SIGNATURE SECTION

I understand that I may be required to submit proof of previous employment, education, military service or other statements in this application. I authorize release of this and other information covering job-related factors for the purpose of verification and determination of suitability for state employment. I state that I have not submitted an application for this written and/or performance examination within the last 30 days. I certify that all the information on this application is true and accurate and understand that misrepresentation of any material fact may be grounds for ineligibility or termination of employment.

Completing this application may result in your name being placed on an eligibility list. Names placed on an eligibility list may be released to the public without further notice to the applicant.

CMS100 (Rev 12/2013)

10.If your answer to either or both of the following questions is “yes”, please provide a detailed explanation of the circumstances in the space provided.

A. Have you ever been fired from a job? (Downsize/layoff is not applicable.)

Yes No

B. Are you currently in default on the repayment of any state educational loan?

Yes No

State law provides that any employee who is in default on the repayment of any education loan for a period of six months or more and in the amount of $600 or more shall, as a condition of employment, make a satisfactory loan repayment arrangement with the maker or guarantor of the loan.

13. TECHNICAL/PROFESSIONAL LICENSE

14.EDUCATION REPORT: LIST YOUR EDUCATION ACCURATELY AND COMPLETELY. A copy of college transcripts/ degrees may be required. The number of credit hours you have earned may be needed to meet the minimum requirements for some titles. This information is also useful for career counseling purposes.

CMS100 (Rev 12/2013)

*LIST UNDERGRADUATE AND GRADUATE HOURS SEPARATELY

*DO NOT INCLUDE COURSES MORE THAN ONCE

Comment area to further specify the Fields of Study where noted in the previous table

CMS100 (Rev 12/2013)

15. WORK HISTORY (continued):

Past Employer

Reason for Leaving:

Past Employer

Reason for Leaving:

CMS100 (Rev 12/2013)

•State law requires that you furnish certain information about your child support obligations at the time you are hired. The possibility of employment is not affected by a child support obligation or default in payment.

•As a condition of employment, state law requires that “every male born on or after January 1, 1960, and less than 27 years old, shall submit documentation, at time of appointment, evidencing his registration with the Federal Selective Service System.”

•In compliance with the state and federal constitutions, the Illinois Human Rights Act, the U.S. Civil Rights Act, the Americans with Disabilities Act, and Section 504 of the Federal Rehabilitation Act, the Department of Central Management Services does not discriminate in employment, contracts, or any other activity. If you have a complaint, please contact the Department of Central Management Services at 217/782-7100 (voice) or 800/526-0844 (TTY Only).

•Pursuant to Public Act 93-0211, effective January 1, 2004, (20 ILCS 2630/12 (a)) and Public Act 93-0912, effective August 12, 2004, (705 ILCS 405/5-915 (8)(a)), respectively, applicants seeking employment with the State of Illinois are not obligated to disclose an arrest or conviction record that has been expunged or sealed, nor an expunged juvenile record. Employers may not ask if an applicant has had records expunged or sealed. Neither Public Act applies to law enforcement agencies, the Department of Corrections, State's Attorneys or other prosecutors.

•Central Management Services requests disclosure of information that is necessary to accomplish its obligations, primarily the statutory purposes outlined under the Personnel Code (20 ILCS 415). Disclosure of the information requested on this form is mandatory, and failure to provide requested information may result in rejection of this form or delay in making a determination on eligibility or employment. Social Security numbers are used in the application and employment processes to identify and differentiate between candidates and/or employees. Confidentiality of Social Security numbers obtained through this application process will be preserved as prescribed by 5 ILCS 179 et seq.

16.This application may be utilized as the actual test for some titles. If the title for which you wish to test is a closed exam or an exam based only on training and experience, mail completed application to:

CMS Bureau of Personnel Examining and Counseling Division Stratton Office Building, Room 500 Springfield, Illinois 62706.

Applications for a closed exam will be held on file until an agency requests that the test be administered or for a maximum of one year from the date of receipt.

The following section is optional.

The State of Illinois is an Equal Opportunity Employer. To assist in the accomplishment of Affirmative Action goals, we invite you to complete the following information. Completion of this information is not required. Check ONE box and, if applicable, check the appropriate Disability box.

See the included State of Illinois Assessment Centers, Testing and Career Counseling Information sheet.

CMS100 (Rev 12/2013)