CT-HR-13 Form – Fill Out and Use This PDF

ADDENDUM TO THE APPLICATION FOR EXAMINATION

OR EMPLOYMENT CT-HR-13 NEW 10/1/2010

STATE OF CONNECTICUT

Addendum to the Application for Examination or Employment (CT-HR-13)

CRIMINAL CONVICTIONS

INSTRUCTIONS TO APPLICANT: You are required to complete this form if the job/position posting states that you must fill out the CRIMINAL CONVICTIONS form (CT-HR-13) or you are requested to fill out the form by a hiring agency. Answers to the following question will be considered for employment purposes if relevant to the position for which you are applying. Per C.G.S. § 46a-80, as amended by, Public Act No. 10-142:

SECTION 1: APPLICANT INFORMATION

_______________________________	_____________________		___	______
LAST NAME	FIRST NAME		MI	SUFFIX (i.e., Jr., MD, Ph.D.)
_________________________________________________________				____________________
MAILING ADDRESS (P.O. Box # or house number and street)				APARTMENT # (if any)
_______________________________________________		______		_________________
CITY		STATE		ZIP CODE

____________________________________________

SOCIAL SECURITY NUMBER

If name was different, list all name(s) used. Include last name, first name and middle initial for each.

_____________________________________ ______________________________________

_________________________________________ ___________________________________________

SECTION 2: APPLICANT CERTIFICATION

I certify that the statements made by me on this application form and attachments, if any, are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatement of fact, I am subject to disqualification and dismissal and to such other penalties as may be prescribed by law or personnel regulations. All statements made on this application, including employment information, are subject to verification as a condition of employment.

Applicant signature: __________________________________	Date: ____________
(Signature is required)

PAGE TWO	_________________________________	____________________	____
	Last Name	First Name	MI

SECTION 3: CRIMINAL CONVICTIONS

Have you ever been CONVICTED of an offense against criminal or military law, or are there criminal charges currently pending against you? (Exclude minor traffic violations or any offense settled in juvenile court or under

a youth offender law.)

___ Yes

___ No

If you answered "Yes", please provide a detailed explanation below about the nature of the conviction, degree of rehabilitation and time since release. Attach an additional sheet of paper if necessary.

Special Note: You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes § 46b-146, 54-76o, or 54-142a. If your criminal records have been erased pursuant to one of these statutes, you may swear under oath that you have never been arrested. Criminal records that may be erased are records pertaining to a finding of delinquency or that a child was a member of a family with service needs (C.G.S. § 46b-146), an adjudication as a youthful offender (C.G.S. § 54-76o), a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon (C.G.S. § 54-142a).