Free EMPLOYMENT APPLICATION - Connecticut

EMPLOYMENT APPLICATION
JD-ES-11 Rev. 3/08 C.G.S. § 31-51i

INSTRUCTIONS: 1. Type or print in ink, answer all questions completely. 2. Form JD-ES-11A MUST be completed and returned with this form to: Judicial Branch, Human Resource Management Unit, 90 Washington St., Hartford, CT 06106 POSITION(S) APPLYING FOR NAME OF APPLICANT (Last, first, middle) NAME AND ADDRESS ADDRESS NAME OF HIGH SCHOOL CITY AND STATE

STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov

AN EQUAL OPPORTUNITY AFFIRMATIVE ACTION EMPLOYER This application may be made available in an alternate format upon request by a qualified individual with a disability under the provisions of the Americans with Disabilities Act. If you need assistance, please contact the Recruitment Section of the Human Resource Management Unit at (860)706-5288. DATE OF APPLICATION

HOME PHONE (with area code)

BUSINESS PHONE (with area code)

"X" here if you are a high school graduate or have received an equivalency diploma. MAJOR SUBJECT DID YOU GRADUATE? DEGREE RECEIVED

Please list all schools you have attended since high school. (Technical, Business, College, or other)
NAME OF SCHOOL CITY AND STATE

EDUCATION

List here only the employment that you believe qualifies you for the position(s) you are applying for. List all other experience in the next section. Begin with PRESENT or MOST RECENT employment and work backwards. If additional space is required, attach an additional sheet using the same format.

1

NAME AND ADDRESS OF EMPLOYER (City and state) JOB TITLE HOURS PER WEEK PER NAME OF IMMEDIATE SUPERVISOR EMPLOYED FROM (Mo , yr ) TO (Mo., yr ) TOTAL (Years, months)

TELEPHONE (with area code) SALARY OR WAGE $

DUTIES (Include knowledge, skills and abilities required)

2
EXPERIENCE

NAME AND ADDRESS OF EMPLOYER (City and state) JOB TITLE HOURS PER WEEK PER NAME OF IMMEDIATE SUPERVISOR EMPLOYED FROM (Mo , yr ) TO (Mo., yr ) TOTAL (Years, months)

TELEPHONE (with area code) SALARY OR WAGE $

DUTIES (Include knowledge, skills and abilities required)

3

NAME AND ADDRESS OF EMPLOYER (City and state) JOB TITLE HOURS PER WEEK PER NAME OF IMMEDIATE SUPERVISOR EMPLOYED FROM (Mo , yr ) TO (Mo., yr ) TOTAL (Years, months)

TELEPHONE (with area code) SALARY OR WAGE $

DUTIES (Include knowledge, skills and abilities required)

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List all other experience. Account for all time since school.
DATE (Mo., Yr.) FROM
GENERAL EXPERIENCE

TO

NAME OF EMPLOYER

ADDRESS (City, State)

JOB TITLE

SALARY

List relevant knowledge, skills and abilities you have acquired in the above employment.
OTHER KNOWLEDGE, SKILLS AND ABILITIES

1. Have you ever been discharged from a job?
IF YES, PLEASE EXPLAIN

YES

NO

2. May we contact your present and past employers for information about your duties?
ADDITIONAL INFORMATION IF NO, PLEASE EXPLAIN

YES

NO

3. Have you ever worked for another branch of government or state agency?
IF YES, INDICATE WHICH OFFICE(S) AND DATES OF EMPLOYMENT (If not indicated above)

YES

NO

List here any licenses or certificates you may hold, which are valid and in good standing.
NAME OR DESCRIPTION
LICENSES AND CERTIFICATES

ISSUED BY

DATE

NUMBER

CERTIFICATION

I certify that the statements made by me on this application are COMPLETE and TRUE to the best of my knowledge and belief and are made in good faith and I have not withheld pertinent information. I understand that if I knowingly make any misstatement of facts, I am subject to disqualification or dismissal and to such other penalties as may be prescribed by law or Judicial Branch policies. I also understand that application and appointment to a temporary position is no guarantee of appointment to a permanent position. Read this application and your answers CAREFULLY before signing.
SIGNED (Applicant) DATE SIGNED

IMPORTANT NOTICE

All offers of employment are contingent on the production of proper documents verifying your eligibility for employment pursuant to the Immigration Reform and Control Act, a federal law. You will be required to produce these documents within the first three days of employment. At your request, the interviewer will inform you concerning the type of documents that will be required. You may also be subject to a criminal history background check.
Form JD-ES-11A MUST be completed and returned with this form.

JD-ES-11 (Page 2) Rev. 3/08

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EMPLOYMENT APPLICATION CRIMINAL HISTORY RECORD
JD-ES-11A Rev. 3/08 C.G.S. § 31-51i

STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov

AN EQUAL OPPORTUNITY AFFIRMATIVE ACTION EMPLOYER This application may be made available in an alternate format upon request by a qualified individual with a disability under the provisions of the Americans with Disabilities Act. If you need assistance, please contact the Recruitment Section of the Human Resource Management Unit at (860)706-5288. DATE OF APPLICATION

INSTRUCTIONS: 1. Type or print in ink, answer all questions completely. 2. Return with completed Employment Application form (JD-ES-11) to: Judicial Branch, Human Resource Management Unit, 90 Washington St., Hartford, CT 06106 POSITION(S) APPLYING FOR NAME OF APPLICANT (Last, first, middle) NAME AND ADDRESS ADDRESS

HOME PHONE (with area code)

BUSINESS PHONE (with area code)

Have you ever been convicted of a criminal offense or an offense against military law? (SEE NOTICE BELOW) (Exclude minor traffic violations or any offense settled in a juvenile court or under a YES NO youthful offender law.) IF YES, GIVE DETAILS (Use additional sheet if necessary)

DETAILS

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(1) You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to C.G.S. §§ 46b-146, 54-76o or 54-142a, (2) criminal records subject to erasure pursuant to C.G.S. §§ 46b-146, 54-76o or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, 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, and (3) any person whose criminal records have been erased pursuant to C.G.S. §§ 46b-146, 54-76o or 54-142a shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath. I certify that the statements made by me on this application are COMPLETE and TRUE to the best of my knowledge and belief and are made in good faith and I have not withheld pertinent information. I understand that if I knowingly make any misstatement of facts, I am subject to disqualification or dismissal and to such other penalties as may be prescribed by law or Judicial Branch policies. I also understand that application and appointment to a temporary position is no guarantee of appointment to a permanent position. Read this application and your answers CAREFULLY before signing.
SIGNED (Applicant) DATE SIGNED

NOTICE

CERTIFICATION

MUST be completed and returned with Employment Application (Form JD-ES-11).

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NAME OF APPLICANT (Last, first, middle)

DETAILS (Continued from previous page):

DETAILS (Continued)

JD-ES-11A (Page 2) Rev. 3/08

EQUAL OPPORTUNITY EMPLOYER

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