Free KCOJ Job Application - Kentucky

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AOC-001-3 Rev. 12-08

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APPLICATION FOR EMPLOYMENT Court of Justice www.courts.ky.gov An Equal Opportunity Employer

Post ID ­ Job Title Name-Location for which you are applying ___________________

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Accommodations are available for applicants with disabilities in all phases of the application and employment process. To request an accommodation please contact the ADA Coordinator at 502-573-2350 or [email protected].

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Personal Information _________________________________________________________________________________________________ Last Name First Name (legal name) Middle Name Preferred Name _________________________________________________________________________________________________ Street/Rural Route /PO Box Apt. Ste or Apt. Box # City State Zip Code (zip last 4 digits) Home County _______________________________ Email Address _______________________________ Driver's License State _________________________ Primary Phone __________________________ Secondary Phone ________________________ Driver's License No ______________________

Are you over the age of 16? ______ If hired, could you provide documentation that you are legally eligible to work in the United States? _________ Commonwealth Employment Status ____ ____ I have retired from an agency under the Kentucky Retirement System (e.g. KRS, CERS, KTRS) Branch/Agency Department _______________________________ Last Year of Employment _______ I am currently/previously employed by an agency under the Kentucky Retirement System (If multiple agencies, list most recent agency below) Branch/Agency Department _______________________________ Last Year of Employment _______ Years of service ________________ Are you currently employed by this agency? __________ If currently employed, are you serving a disciplinary probation? ________ I have never been employed by an agency under the Kentucky Retirement System

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Resumes without a completed application will not be considered.

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Certifications 1. Date Certified _______________ Date Expiration _________________ Certification Number ____________________ Profession ____________________________ Licensing Agency ___________________________________________ _______________________________________________________________________________________________ Agency Address and Telephone Number 2. Date Certified _______________ Date Expiration _________________ Certification Number ____________________ Profession ____________________________ Licensing Agency ___________________________________________ _______________________________________________________________________________________________ Agency Address and Telephone Number Criminal History Failure to disclose any convictions shall result in an automatic rejection of application and any offer of employment. A conviction is the act or process of judicially finding someone guilty of a crime; the state of having been proven guilty. If applicable, list all convictions, including traffic violations. A conviction is not an automatic rejection. Specifics will be reviewed. 1. Date Convicted __________ State Convicted ______________ Details ___________________________________________________________________________________________ 2. Date Convicted __________ State Convicted ______________ Details ___________________________________________________________________________________________ 3. Date Convicted __________ State Convicted ______________ Details ___________________________________________________________________________________________

Education ­ Any certifications/degrees may be requested at any time through the hiring process. ___ I have graduated high school. ___ I have a GED. High School Name and Address or GED certification location address _________________________________________________________________________________________________ 1. College/University/Vocational/MilitaryName______________________________________________________________ Address ______________________________________________________________________________________ Degree Name ______________________________________ Type of Degree ___________________________ Major_____________________________________________ Date Earned ____________________________ Date Attended From __________To _________ Hours Completed _______ Hours Carrying ______ 2. College/University/Vocational/MilitaryName______________________________________________________________ Address ______________________________________________________________________________________ Degree Name ______________________________________ Type of Degree ___________________________ Major_____________________________________________ Date Earned ____________________________ Date Attended From __________To _________ Hours Completed _______ Hours Carrying ______ 3. College/University/Vocational/MilitaryName______________________________________________________________ Address ______________________________________________________________________________________ Degree Name ______________________________________ Type of Degree ___________________________ Major_____________________________________________ Date Earned ____________________________ Date Attended From __________To _________ Hours Completed _______ Hours Carrying ______ Employment List the most recent employment history first. Military experience may be listed in this section. 1. Date From __________ Date To _________ ( )Current Employer Name ____________________________________ Employer Address ______________________________________________________________________________ Employer Phone ____________________________________ Supervisor's Name _______________________ Supervisor's email ____________________________________ Average Hours Per Week __________________ Starting Salary _________________Last Salary ____________ Reason for Leaving _______________________ Number of persons you supervised __________ Job Title _______________________________ Duties ________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 2. Date From __________ Date To _________ ( )Current Employer Name ____________________________________ Employer Address ______________________________________________________________________________ Employer Phone ____________________________________ Supervisor's Name _______________________ Supervisor's email ____________________________________ Average Hours Per Week __________________ Starting Salary _________________Last Salary ____________ Reason for Leaving _______________________ Number of persons you supervised __________ Job Title _______________________________ Duties ________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 3. Date From __________ Date To _________ ( )Current Employer Name ____________________________________ Employer Address ______________________________________________________________________________ Employer Phone ____________________________________ Supervisor's Name _______________________ Supervisor's email ____________________________________ Average Hours Per Week __________________ Starting Salary _________________Last Salary ____________ Reason for Leaving _______________________ Number of persons you supervised __________ Job Title _______________________________ Duties ________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

4. Date From __________ Date To _________ ( )Current Employer Name ____________________________________ Employer Address ______________________________________________________________________________ Employer Phone ____________________________________ Supervisor's Name _______________________ Supervisor's email ____________________________________ Average Hours Per Week __________________ Starting Salary _________________Last Salary ____________ Reason for Leaving _______________________ Number of persons you supervised __________ Job Title _______________________________ Duties ________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 5. Date From __________ Date To _________ ( )Current Employer Name ____________________________________ Employer Address ______________________________________________________________________________ Employer Phone ____________________________________ Supervisor's Name _______________________ Supervisor's email ____________________________________ Average Hours Per Week __________________ Starting Salary _________________Last Salary ____________ Reason for Leaving _______________________ Number of persons you supervised __________ Job Title _______________________________ Duties ________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 6. Date From __________ Date To _________ ( )Current Employer Name ____________________________________ Employer Address ______________________________________________________________________________ Employer Phone ____________________________________ Supervisor's Name _______________________ Supervisor's email ____________________________________ Average Hours Per Week __________________ Starting Salary _________________Last Salary ____________ Reason for Leaving _______________________ Number of persons you supervised __________ Job Title _______________________________ Duties ________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Related Information You may add any information in this section related to professional organizations, related experience, languages you can read/write/speak, equipment knowledge, and/or skills/abilities. This section may be used for preferred selection of qualified candidates. Please list dates you were a member of organizations, any titles held, and duties of the positions held. 1. Date From _______ Date To _______ _______________________________________________________________ Details___________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ 2. Date From _______ Date To _______ _______________________________________________________________ Details___________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ 3. Date From _______ Date To _______ _______________________________________________________________ Details___________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ Availability ____ I can work anywhere in Kentucky Date Available ____________________ ____ First Shift ___ Second Shift ___ Third Shift _____Any Shift Counties desired for work locations _____________________________________ __________________________________________________________________

References Please list at least 3 references other than relatives and former supervisors. 1. _____________________________________________________________________________________________ Last Name First Name Email Address Phone _____________________________________________________________________________________________ Street/Rural Route /PO Box Apt. Ste or Apt. Box # City State Zip Code (zip last 4 digits) 2. _____________________________________________________________________________________________ Last Name First Name Email Address Phone _____________________________________________________________________________________________ Street/Rural Route /PO Box Apt. Ste or Apt. Box # City State Zip Code (zip last 4 digits) 3. _____________________________________________________________________________________________ Last Name First Name Email Address Phone _____________________________________________________________________________________________ Street/Rural Route /PO Box Apt. Ste or Apt. Box # City State Zip Code (zip last 4 digits) Statistics EQUAL EMPLOYMENT OPPORTUNITY (EEO) Qualified applicants are considered for employment without regard to race, religion, sex, national origin, age, marital status, sexual orientation, veteran status, disability, or other protected classification as defined by applicable law and regulation. As the employer, we may be subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite applicants to voluntarily complete these statistics. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. Race/Ethnicity ____White ____Black or African American ____Hispanic or Latino ____Asian ____American Indian or Alaskan Native ____Other ____Native Hawaiian or other Pacific Islander ____Two or more races Gender ____Female ____Male Date of Birth _________________ ____No Highest Degree Obtained ______________

Are you a veteran of the United States Armed Forces? ____Yes Signature

I certify that the information given in this application is correct and complete to the best of my knowledge. I am aware that should an investigation at any time show any falsification, I may not be considered for employment or, if employed, I may be dismissed and disqualified from employment. I hereby authorize the Court of Justice to make all necessary investigations concerning me, my future work, habits, character, or my action in any transaction. I authorize the Court of Justice to receive my academic records or other material pertinent to my qualifications, and further authorize and request each former employer (including COJ, if applicable), person given as a reference, educational institution, or organization (including law enforcement agencies) to provide all (including COJ, if applicable) information that may be sought in connection with this application. I certify that I can perform the essential functions of the position for which I am applying, with or without reasonable accommodations. I certify that I am the person that is listed in name on this application. _________________________________________________________________________________________________ Applicant Signature Date Where did you hear about us? (please check one) [ ] Friend [ ] Job Fair [ ] Newspaper [ ] Web Search [ ] University [ ] Link [ ] Other__________________________________________________________________________________