Form Ct Hr 12 – Fill Out and Use This PDF

APPLICATION FOR EXAMINATION	SOCIAL SECURITY NUMBER: ____ ____ ____ -____ ____ - ____ ____ ____ ____
OR EMPLOYMENT CT-HR-12 NEW 10/1/2010
(formerly Form PLD-1)	________________________________________	_______________________	____
	Last Name	First Name	MI

STATE OF CONNECTICUT

Application for Examination or Employment (CT-HR-12)

DO NOT WRITE	APPROVED________ DISAPPROVED________		REVIEWED BY: __________	AE Date: __________
in shaded area
GE – Lack GE	LS – Length SE	GS – Length GE, Lack SE	AS – No Agency Status	SI – No Supp Exam Mat.
LG – Length GE	ET – Lack GE, SE	EM – Not Current St Emp	ST – No Classified Status	II – Insufficient Info
SE – Lack SE	LL – Length GE, SE	AR – Emp not Hiring Agency	CS – Status in Class	LT – Late

INSTRUCTIONS TO APPLICANT: Read the detailed instructions on the final page of this application and on the examination announcement or position/job posting before completing this application form. Type or print answers to ALL questions.

SECTION 1: APPLICANT CONTACT 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
List other name(s) you have used. Include last name, first name and middle initial for each.
_____________________________________		______________________________________

I may also be contacted at the phone numbers or via e-mail as indicated below. Consider the best numbers to reach you during normal business hours (EST) and check off the type of communication.

(____)______-________ (____)______-________		______________________________
PRIMARY PHONE #	SECONDARY PHONE #	E-MAIL ADDRESS
___ Cell ___Work ___Home	___ Cell ___Work ___Home
SECTION 2: PURPOSE OF APPLICATION (CHECK ONE):
___ STATE EXAMINATION	___ STATE POSITION/JOB POSTING

Complete the required information below for one examination OR one position only:

If you are applying for a State of Connecticut examination complete the following information as it appears on the examination announcement:

Examination Title: ___________________________________________ Exam No.: _____________

OR

If you are applying for a State of Connecticut position/job complete the following information as it appears on the posting.

Position/Job Title: ______________________________________ Job Posting No.: ___________

PAGE TWO	________________________________________	_______________________	____
	Last Name	First Name	MI
	______________________________________________________________________
	Examination Title or Position Title

SECTION 3 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)

SECTION 4: STATE EMPLOYMENT HISTORY (To be completed by current or former State of CT employees)

Are you a current State of Connecticut employee? __Yes __No If ‘Yes: __________________

	6-digit Employee ID #
_____________________________________	_________________________________________
Official Job Class Title	Employing Agency, Department, College/University

If you are not a current State of Connecticut employee but worked for the State of Connecticut previously, did you leave State service within the past 10 years? __Yes __No

If ‘Yes’ complete dates of employment from: ____/____/_______to ____/____/_______

_____________________________________	_________________________________________
Official Job Class Title at time of separation	Employing Agency, Department, College/University

Reason for leaving: ________________________________________________________________

SECTION 5: APPLICANT EDUCATION

A.Primary and Secondary Education

Have you graduated from high school or received a high school equivalency diploma (GED)?

__Yes __No

PAGE THREE	________________________________________	_______________________	____
	Last Name	First Name	MI
	______________________________________________________________________
	Examination Title or Position Title

SECTION 5: APPLICANT EDUCATION (continued)

B.College Education

	1.) ______________________________________				______________________			___	__________
	Name of College or University Attended					City		State		Country*
	Is this college accredited**?	__Yes	__No	Dates of Attendance: From: ___/_____To:___/_____
							(MM/YYYY)		(MM/YYYY)
	Type of degree completed:	__Associate		__Bachelor		__Master	__Doctorate	__Law		__None
	If ‘None’ please indicate the number of credit hours completed: ____
	If a degree was conferred, complete the following information for this college/university:
	_____________________________________					________________________________________
	Major Course of Study					Major Course of Study (only if double major)
	2.) ______________________________________				______________________			___	__________
	Name of College or University Attended					City		State		Country*
	Is this college accredited**?	__Yes	__No	Dates of Attendance: From: ___/_____To:___/_____
							(MM/YYYY)		(MM/YYYY)
	Type of degree completed:	__Associate		__Bachelor		__Master	__Doctorate	__Law		__None
	If ‘None’ please indicate the number of credit hours completed: ____
	If a degree was conferred, complete the following information for this college/university:
	_____________________________________					________________________________________
	Major Course of Study					Major Course of Study (only if double major)
	3.) ______________________________________				______________________			___	__________
	Name of College or University Attended					City		State		Country*
	Is this college accredited**?	__Yes	__No	Dates of Attendance: From: ___/_____To:___/_____
							(MM/YYYY)		(MM/YYYY)
	Type of degree completed:	__Associate		__Bachelor		__Master	__Doctorate	__Law		__None
	If ‘None’ please indicate the number of credit hours completed: ____
	If a degree was conferred, complete the following information for this college/university:
	_____________________________________					________________________________________
	Major Course of Study					Major Course of Study (only if double major)

Attach additional sheets (labeled with “Section 5 – continued” and include your name and examination number/title or position title in upper right corner) if you attended more than three (3) colleges/universities.

*- If the institution of higher learning is located outside of the United States, you are responsible for providing documentation from a recognized USA accrediting service which specializes in determining foreign education equivalencies. The responsibility for and the costs associated with obtaining this equivalency information rests with you, the applicant.

** - In order to receive educational credit towards admittance to an examination, the institution must be recognized by the CT Department of Higher Education as an accredited institution (www.chea.org).

PAGE FOUR	________________________________________	_______________________	____
	Last Name	First Name	MI
	______________________________________________________________________
	Examination Title or Position Title

SECTION 5: APPLICANT EDUCATION (continued)

C.Technical, Business or Other Education

1.) ______________________________________ ______________________			___	__________
Name of School Attended		City	State	Country*
Dates of Attendance: From: _____/_____To:_____/_____		________________________________
(MM/YYYY)	(MM/YYYY)	Type of degree or certificate earned

2.) ______________________________________ ______________________			___	__________
Name of School Attended		City	State	Country*
Dates of Attendance: From: _____/_____To:_____/_____		________________________________
(MM/YYYY)	(MM/YYYY)	Type of degree or certificate earned

SECTION 6: REQUIRED LICENSES AND CERTIFICATIONS

Do you have any valid licenses or certificates which authorize you to practice a profession or trade?

(e.g. law, nursing, psychology, plumbing, etc.) ___Yes

___No

If yes, please complete the following section:

1.) Type of License: ________________ License #: ____________ Issued By: _________________

Date Issued: ____/____	Expiration Date: ____/____
(MM/YY)	(MM/YY)

2.) Type of License: ________________ License #: ____________ Issued By: _________________

Date Issued: ____/____	Expiration Date: ____/____
(MM/YY)	(MM/YY)

Do you currently have a valid Motor Vehicle Driver’s License? __Yes __No State: ____________

Do you currently have a valid Commercial Driver’s License (CDL)?__Yes __No State: __________

PAGE FIVE	________________________________________	_______________________	____
	Last Name	First Name	MI
	______________________________________________________________________
	Examination Title or Position Title

SECTION 7: EMPLOYMENT HISTORY

Important Instructions for Completing this Section. Beginning with your PRESENT or MOST RECENT employment or volunteer experience and working backward, list all positions held that you wish to be considered toward meeting the eligibility requirements (minimum qualifications) stated on the exam announcement or job posting. List all positions (job titles) separately, even if with the same employer. Provide the starting and ending dates (month, day and year) of your employment for each position and indicate if the position was full or part time and the number of hours worked per week. Clearly describe the work (duties) you personally performed in each position. If a job included a mixture of relevant duties and other duties that are not relevant toward meeting the eligibility requirements, you must also provide the percent of time you performed these different duties. Number your jobs, starting with your most recent job as number 1. Make additional copies of this page as needed to list additional positions, and continue the number sequence. If you need additional space for the descriptions of your duties for one or more positions, attach an 8 1/2” x 11” sheet with your name and the exam number or position title and continue the descriptions of your duties, using the number sequence to identify which positions the duties belong to. You must fill out this application completely even if you attach a resume. Failure to provide all of the REQUIRED information for each position (or job title) held may result in your application being disapproved. Although a resume can be attached, only jobs included in this section of the application form will be considered when determining if you meet the required minimum qualifications for the exam or position for which you are applying.

POSITION 1: ________________________________________ _____________________________________________

Most Recent Official Job Title			Company Name/Department where assigned
_________________________________________________			____________________	_______	____________
Business Address (P.O. Box or # and Street)			City	State	Zip Code
___________________________________________		_________________________________________________
Type of Business			Official Job Title of Immediate Supervisor
Dates of Employment: From: ___/____/____To:___/____/____			Phone Number: ________________________
(MM/DD/YY)	(MM/DD/YY)		Annual Salary/Hourly Wage: ______________
This job is/was: ___ Full-time ___ Part-time	____ Per Diem		Number of Hours Worked per week: _______

Number & Job Titles of Employees Supervised by you: ____________________________________________________

Reason for leaving: ________________________________________________________________

List all major duties and responsibilities performed by you in this job. (This area must be completed for each job listed.)

PAGE SIX	________________________________________			_______________________		____
			Last Name	First Name		MI
	______________________________________________________________________
SECTION 7: EMPLOYMENT HISTORY (CONTINUED)			Examination Title or Position Title
POSITION 2: ________________________________________ _____________________________________________
Official Job Title			Company Name/Department where assigned
_________________________________________________			____________________	_______	____________
Business Address (P.O. Box or # and Street)			City	State	Zip Code
___________________________________________		_________________________________________________
Type of Business			Official Job Title of Immediate Supervisor
Dates of Employment: From: ___/____/____To:___/____/____			Phone Number: ________________________
(MM/DD/YY)	(MM/DD/YY)		Annual Salary/Hourly Wage: ______________
This job is/was: ___ Full-time ___ Part-time	____ Per Diem		Number of Hours Worked per week: _______

Number & Job Titles of Employees Supervised by you: ____________________________________________________

Reason for leaving: ________________________________________________________________

List all major duties and responsibilities performed by you in this job. (This area must be completed for each job listed.)

POSITION 3: ________________________________________ _____________________________________________

Official Job Title			Company Name/Department where assigned
_________________________________________________			____________________	_______	____________
Business Address (P.O. Box or # and Street)			City	State	Zip Code
___________________________________________		_________________________________________________
Type of Business			Official Job Title of Immediate Supervisor
Dates of Employment: From: ___/____/____To:___/____/____			Phone Number: ________________________
(MM/DD/YY)	(MM/DD/YY)		Annual Salary/Hourly Wage: ______________
This job is/was: ___ Full-time ___ Part-time	____ Per Diem		Number of Hours Worked per week: _______

Number & Job Titles of Employees Supervised by you: ____________________________________________________

Reason for leaving: ________________________________________________________________

List all major duties and responsibilities performed by you in this job. (This area must be completed for each job listed.)

PAGE NINE	________________________________________	_______________________	____
	Last Name	First Name	MI
	______________________________________________________________________
	Examination Title or Position Title

SECTION 9: POSITION INFORMATION

What type(s) of position(s) will you consider? Check all that apply:

__Full-Time	__Part-Time	___Either Part-time or Full-time
__Permanent	__ Nonpermanent ___Either Permanent or Nonpermanent

SECTION 10: EMPLOYMENT DISTRICTS

Check the box(es) for ONLY the district(s) in which you will accept employment. Indicate your choice of location preference(s) in the left hand column by checking the appropriate box(es) where you are willing to work. Not all jobs are used in all locations. Names will be certified by location at the request of the appointing authority.

__ A All Locations

__ B Greenwich, Stamford, New Canaan, Darien __ C Norwalk, Wilton, Weston, Westport

__ D Fairfield, Easton, Monroe, Trumbull, Shelton, Stratford, Milford __ E Bridgeport

__ F Redding, Ridgefield, Danbury, Bethel, Newton, Brookfield, New Fairfield, Bridgewater, Sherman, New Milford, Roxbury, Washington, Kent, Warren

__ G Morris, Litchfield, Harwinton, New Hartford, Torrington, Goshen, Cornwall, Sharon, Salisbury, Canaan, North Canaan, Norfolk, Colebrook, Winchester, Hartland, Barkhamsted

__ H Thomaston, Bethlehem, Watertown, Woodbury, Southbury, Middlebury, Beacon Falls, Naugatuck, Prospect, Waterbury, Wolcott, Cheshire

__ I Oxford, Seymour, Ansonia, Derby

__ J West Haven, Orange, Woodbridge, Bethany, Hamden, North Haven, East Haven, North Branford, Wallingford, Branford, Guilford, Madison, Clinton

__ K New Haven __ L Meriden

__ M Plymouth, Bristol, Burlington

__ N Berlin, Southington, Plainville, New Britain __ O Avon, Farmington, West Hartford

__ P East Hartford, Manchester __ Q Hartford

__ R Granby, Canton, Simsbury, Suffield, East Granby, Windsor Locks, Windsor, Bloomfield, East Windsor, South Windsor, Ellington, Vernon, Tolland, Stafford, Willington

__ S Enfield, Somers

__ T Newington, Wethersfield, Rocky Hill

__ U Union, Ashford, Mansfield, Chaplin, Hampton, Windham, Scotland, Lebanon

__ V Cromwell, Portland, Middletown, Middlefield, Durham, East Hampton, Haddam, East Haddam, Chester, Essex, Killingworth, Deep River, Westbrook, Old Saybrook

__ W Lyme, Old Lyme, East Lyme, Salem, Montville, Waterford, New London, Ledyard, Groton, Stonington, North Stonington

__ X Bozrah, Franklin, Norwich, Sprague, Lisbon, Preston, Griswold, Voluntown

__ Y Woodstock, Thompson, Putnam, Pomfret, Eastford, Brooklyn, Canterbury, Plainfield, Sterling, Killingly

__ Z Glastonbury, Marlborough, Colchester, Hebron, Columbia, Andover, Bolton, Coventry

PAGE TEN	________________________________________	_______________________	____
	Last Name	First Name	MI
	______________________________________________________________________
	Examination Title or Position Title

SECTION 11: TESTING ACCOMMODATIONS FOR EXAMINATIONS

Qualified individuals with a disability may request special testing accommodations under provisions of the Americans with Disabilities Act (ADA) by contacting DAS Statewide Human Resources at 860-713-5206 (voice) and at 860-713-7463 (TDD) immediately upon submitting an application for this examination. Provide your name, exam title and number, a description of your specific needs and documentation from a health care provider verifying your disability.

SECTION 12: VOLUNTARY

In order to meet State and Federal reporting requirements, we are requesting that you voluntarily supply the following information. This data will not be considered in the evaluation of your application.

A. SEX:

___ Female

___ Male

B. RACE/ETHNIC DATA:

__ 1 AMERICAN INDIAN OR ALASKAN NATIVE: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.

__ 2 ASIAN/ PACIFIC ISLANDER: Persons having origins in any of the original peoples of the Far East, Southeast Asia the Indian Subcontinent or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa.

__ 3 BLACK/AFRICAN-AMERICAN (NOT OF HISPANIC ORIGIN): Persons having origins in any of the black racial groups of Africa.

__ 4 HISPANIC: Persons of Mexican, Puerto Rican, Central or South American or other Spanish culture or origin, regardless of race.

__ 5 WHITE (NOT OF HISPANIC ORIGIN): Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

C. PRIMARY SOURCE OF EXAM/JOB INFORMATION:

Where did you learn about this exam or job/position? (Check and complete below.)

__ 1 State of Connecticut Internet site. Website: _______________________________________

__ 2 Other Internet Site. Website: __________________________________________________

__ 3 Newspaper, professional journal, radio or TV advertisement.

Please give the name of the publication/station, etc: _________________________________

__ 4 Paper Posting

__ 5 Direct e-mail or paper mailing.

__ 6 Career fair. Event/Location: ____________________________________________________

__ 7 Other. Please specify: ________________________________________________________

INSTRUCTIONS FOR COMPLETING AND SUBMITTING THE

STATE OF CONNECTICUT

APPLICATION FOR EXAMINATION OR EMPLOYMENT (FORM CT-HR-12)

PLEASE READ CAREFULLY BEFORE COMPLETING THE APPLICATION

GENERAL INFORMATION AND INSTRUCTIONS

This application form is the official State of Connecticut Application Form for Examination or Employment effective October 1, 2010. PLD-1 application forms should not be used on or after October 1, 2010. Check the State Employment Pages on the DAS website (www.das.state.ct.us/exam) for more detailed information about completing the State Application Form and about state examinations, job opportunities and e-alerts.

1.This application form can be used to apply for currently posted State of Connecticut examinations or currently posted job opportunities (position/job postings). If you are applying for a currently posted examination, make certain you include the examination title and examination number. If you are applying for a currently posted job/position, make certain you include the position title and position number.

2.Type or print (in ink) all information requested on the application form. It is critical that you complete all sections of the application form and that all of the information you provide is true and accurate.

3.Give complete and accurate information about your education, work experiences and licenses/certifications as it relates to the minimum requirements for the examination or position for which you are applying. The information you provide on your application form will be used to determine if you meet the requirements as outlined on the examination announcement or position posting. (Resumes may be included as a supplement to the application form, but they will not substitute for any information required on the application form.)

4.Write your name and examination or position title on the top of all pages of your application form. Write your social security number on the top of Page 1.

5.Make certain you sign and date Section 3 of your application form.

6.Make a copy of your application package for your records before submission.

7.Application packages sent to an incorrect address/fax will not be accepted. Carefully review the application filing instructions on the examination announcement or the position posting to ensure your application materials are sent to the correct location.

8.Late and/or incomplete application packages will not be accepted.

INSTRUCTIONS IF YOU ARE APPLYING FOR A CURRENTLY POSTED EXAMINATION

1.Obtain a copy of the examination announcement before completing this application. The announcement includes important information such as: the examination title and number, minimum requirements for admission to the examination, closing date for application package, and other job-related information. In many cases the exam announcement also contains special filing instructions which detail exam materials that must be submitted with the

application form. Examination announcements can be obtained from the DAS website (http://www.das.state.ct.us/exam). Follow all application and examination instructions very carefully!

2.A separate application form must be submitted for each examination for which you are applying.

3.Applications (and supplemental exam materials, if required) for examinations are always submitted to the Statewide Human Resources Management Division at the Department of Administrative Services. Refer to the examination announcement for the mailing address and secure fax number for submitting your application form (and exam materials, if required).

4.Applications received for which there is no current examination announcement are not accepted.

5.This application is not to be used for the following examinations: State Police Trooper Trainee, Correction Officer, Protective Services Trainee (Police) and State Marshall. When these examinations are open you will find special Internet application forms on the DAS website (http://www.das.state.ct.us/exam).

INSTRUCTIONS IF YOU ARE APPLYING FOR A CURRENTLY POSTED JOB/POSITION

1.Obtain a copy of the job/position posting before completing this application. The posting includes important information such as: the position title and position number, minimum requirements for the position, closing date for applications, and other job-related information. The posting also contains application filing instructions which detail what documents need to be submitted to apply for the position and where and how to submit your application package. Follow all application filing instructions very carefully!

2.A separate application form must be submitted for each position you are applying for.

3.Applications are only accepted for currently posted positions.

4.Applications for positions are to be sent to the hiring agency. They are not to be sent to the Department of Administrative Services, unless the position posting specifically directs you to do so.