Ohio Form Gen 4268 – Fill Out and Use This PDF

Ohio Civil Service Application

for State and County Agencies

GENGEN--42684268((REVISEDED01/12)06/08)

The stStatete off Ohiohio isisananEqualEqualOpportunityOpportunityEEmployerployer andandproviderproviderofofADAADAservicesservices..

POSITION:DEPARTMENT:

Please submit one application per position or examination to the address indicated on the job posting or examination announcement.

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ALACHUA COUNTY EMPLOYMENT APPLICATION

or postmarked by the closing date, as required by the hiring agency. Please be sure to complete the entire application. Also note that,

onceIt issubmittedimportanttothatgovernmentalyou answeragency,all questionsthis completedon this formapplicationwill be fsully,bjectastofalilureapplicableto do sopublicmayrecordsdelay considerationlaws. for employment or result in loss of employment opportunities. If an item does not apply to you, write NA (not applicable).

PLEASETYPE ORPRINTINININKINK

NAME: (Last, First, Middle)

DATE OF BIRTH - Year Not Required

Month

Day

ADDRESS: (Street,City,State,ZIPZipCode)

HOME PHONE:

ALTERNATE PHONE:

EM-MAILIA AADDRERD

SSS:

DRIVER’S LICENSE:

LEGAL RIGHT TO WORK IN

Yes

No

STATE:

CLASS:

THE U. S.:

Yes

No

PREFERENCES

PREFERRED SALARY:		ARE YOU WILLING TO RELOCATE?
		Yes	No	Maybe
WHAT TYPE OF JOB ARE YOU LOOKING FOR?		TYPES OF WORK YOU WILL ACCEPT:
Regular	Temporary	Full-Time		Part-Time

SHIFTS YOU WILL ACCEPT:

EDUCATION

HIGH SCHOOL NAME:

LOCATION: (City, State)

LOCATION: (City, State)

DID YOU GRADUATE?

£ Yes

£ No

CHECK YEAR COMPLETED:

9

10

11

12

OBTAINEDDID YOU GRADUATE?GED?

Yes

No

SCHOOL NAME (College/University):

LOCATION: (City, State)

CHECK YEAR COMPLETED:

DID YOU GRADUATE?

MAJOR:

1

2

3

4

5

6

Yes

No

DEGREE RECEIVED:

NUMBER OF QUARTER/SEMESTER

HOURS COMPLETED:

SCHOOL NAME (College/University):

LOCATION: (City, State)

CHECK YEAR COMPLETED:

DID YOU GRADUATE?

MAJOR:

1

2

3

4

5

6

Yes

No

DEGREE RECEIVED:

NUMBER OF QUARTER/SEMESTER

HOURS COMPLETED:

SCHOOL NAME (College/University):

LOCATION: (City, State)

CHECK YEAR COMPLETED:

DID YOU GRADUATE?

MAJOR:

1

2

3

4

5

6

Yes

No

DEGREE RECEIVED:

NUMBER OF QUARTER/SEMESTER

HOURS COMPLETED:

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he purpose of questions 1-11 is to obtain information relevant to employment with the State of Ohio.

Responses to these questions are required.

1.Please indicate your county of residence. _________________________

2.Summary of Qualiications - In the area below, briely describe the experience, education, training and other factors that qualify you for the position or examination for which you are applying. Refer to the Minimum Qualiications and any position-speciic qualiications posted for this position or examination. If you need additional space, attach an extra sheet to this application.

3.Please list below the speciic course work areas at the high school level or beyond relevant to the position or examination for which you are applying. Also indicate the number of courses you have successfully completed in each area. Note: A transcript may not be substituted for this section, although you may be required to submit a transcript.

4.Are you a current State of Ohio employee?

___Yes, I’m a permanent employee

___Yes, I’m an interim or intermittent employee

___Yes, I’m a temporary, seasonal or project employee

___Yes, I’m a ixed term or established term employee

___No, I’m not a State of Ohio employee

5.If you are a current State of Ohio employee, please provide your eight (8) digit, OAKS ID number. If you are not a current State of Ohio employee, please type N/A. _________________________

6.If you are not a current State of Ohio employee, have you ever been employed by the State of Ohio? (If you are a current State of Ohio employee, please select N/A.)

___ Yes ___ No ___N/A

7.If you were previously employed by the State of Ohio, please choose one of the following:

___ Employment ended prior to 12-01-2004.

___ Employment ended on or ater 12-01-2004.

___ N/A - Not previously employed by the State of Ohio or current state employee.

8.If you were previously employed by the State of Ohio, have you ever plead guilty or been convicted of a misdemeanor, for violation of Ohio Revised Code 1347.15 (H)(1) and/or (H)(2) - Access rules for conidential personal information?

___ Yes ___ No

9.Have you ever been convicted of a felony? (A felony conviction may not automatically exclude you from consideration.)

___ Yes ___No

10.If you answered Yes to the previous question, please give date(s) of conviction(s) and explain. If you answered No, please type N/A.

11.How did you learn about this employment or examination opportunity?

___ careers.ohio.gov	___ Monster.com	___ Trade journal	___ Walk-in
___ Ohiomeansjobs.com	___ Other Internet Web site	___ State of Ohio Employee Referral	___ Other
___ GovernmentJobs.com	___ Newspaper	___ Civil Service test announcement

CERTIFICATION

I certify that the answers I have made to all of the questions in this application are true and complete to the best of my knowledge. I understand that if this application is not completed in its entirety, it will not be processed and I will be automatically disqualiied. I understand that I am responsible for the correctness of this application. I also understand that a background check may be required prior to employment and that, in accordance with the Drug-Free Workplace Program, drug testing may be required. I waive all provisions of law forbidding colleges or universities which I attended, or past employers, from disclosing any information which they acquired relevant to my employment. I consent that they may disclose such information to the Human Resources Division, Ohio Department of Administrative Services, and/or the agency that holds the vacancy for which I am applying and to appropriate oicials for recruitment purposes. I understand that any ofer of employment is conditional upon proof of legal authorization to work in the United States as required by the Immigration Reform and Control Act.

Signature of Applicant _____________________________________________________________________________ Date ___________________

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