APPLICATION FOR EMPLOYMENT - Connecticut
APPLICATION FOR EMPLOYMENT
THIS IS A SAMPLE APPLICATION - DO NOT USE TO APPLY TO THE DEPARTMENT OF LABOR INSTRUCTIONS: Type or print answers to ALL questions
DATE
SOCIAL SECURITY NUMBER NAME (Last)
(First)
(MI) SUFFIX (JR.)
ADDRESS (Number and Street)
CITY
STATE ZIP CODE (Last 4 digits are optional)
AREA CODE
HOME PHONE NUMBER
DAYS/HOURS AVAILABLE TO WORK
POSITION APPLIED FOR
DESIRED HOURLY RATE OF PAY
Drivers License
What kind of position are you applying for?
Full time
Part time
EDUCATION: Have you graduated from High School or received a High School equivalency diploma?
SCHOOL
NAME
ADDRESS
HIGH SCHOOL
Yes Either
No
If you are 17 years old or
younger, enter your age
HOW MANY HOURS CAN YOU WORK PER WEEK?
Yes
No
DATES ATTENDED
FROM TO
If No, circle highest grade completed: 1 2 3 4 5 6 7 8 9 10 11 12
CREDIT HOURS COMPLETED
TYPE OF DEGREE RECEIVED
MAJOR COURSE
OF STUDY
DID YOU GRADUATE?
TECHNICAL OR
BUSINESS
COLLEGE OR
UNIVERSITY
HAVE YOU EVER BEEN CONVICTED OF A CRIME?
Yes
No
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type of rehabilitation.
List additional skills, knowledge and abilities you possess:
Adapted from the Department of Administrative Services, PLD-1, by the Connecticut Department of Labor, 200 Folly Brook Boulevard, Wethersfield, CT 06109
INSTRUCTIONS
Beginning with your PRESENT OR MOST RECENT employment or volunteer experience and working backward, list all positions held which are necessary for determining your eligibility for employment. List all positions (titles) separately; even if with the same employer. Clearly describe the work (duties) you personally performed. You must fill out this application completely even if a resume is being attached.
Official Job title (Start with most recent job)
Company Name
Type of Business
Title of Immediate Supervisor
Dept. Where Assigned
Business Address/Phone No.
Employed From:
To:
Total (Yrs. Mos.) Salary or Wage
(Mo.)
(Yr.)
(Mo.)
(Yr.)
$
Per
No. and Titles of Employees Supervised by You
Reason for Leaving
Hours Per Week
(Full-time)
(Part-time)
DUTIES (must be listed)
Official Job title (Start with most recent job)
Company Name
Title of Immediate Supervisor
Dept. Where Assigned
Employed From:
(Mo.)
(Yr.)
To: (Mo.)
Total (Yrs. Mos.) (Yr.)
No. and Titles of Employees Supervised by You
DUTIES (must be listed)
Type of Business
Business Address/Phone No.
Salary or Wage
$
Per
Reason for Leaving
Hours Per Week
(Full-time)
(Part-time)
Official Job title (Start with most recent job)
Company Name
Title of Immediate Supervisor
Dept. Where Assigned
Employed From:
(Mo.)
(Yr.)
To: (Mo.)
Total (Yrs. Mos.) (Yr.)
No. and Titles of Employees Supervised by You
DUTIES (must be listed)
Type of Business
Business Address/Phone No.
Salary or Wage
$
Per
Reason for Leaving
Hours Per Week
(Full-time)
(Part-time)
CERTIFICATION:
I certify that the statements made by me on this application 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.
SIGNED: __________________________________________________________________________ DATE: _____________________________
Adapted from the Department of Administrative Services, PLD-1, by the Connecticut Department of Labor, 200 Folly Brook Boulevard, Wethersfield, CT 06109
APPLICATION FOR EMPLOYMENT
INSTRUCTIONS: Type or print answers to ALL questions
DATE
12/30/02
SOCIAL SECURITY NUMBER
NAME (Last)
Application
ADDRESS (Number and Street)
125 Main Street
123
(First)
Job
45
6789
(MI) SUFFIX (JR.)
L. -
CITY
Anywhere
STATE ZIP CODE (Last 4 digits are optional)
CT 01111
AREA CODE
987
HOME PHONE NUMBER
654-3210
POSITION APPLIED FOR
Sales Clerk
DAYS/HOURS AVAILABLE TO WORK
Monday ? Friday 3:30 pm ? 8:00 pm Saturday, Sunday 8am ? 10 pm
DESIRED HOURLY RATE OF PAY
Minimum wage
What kind of position are you applying for?
Full time
Drivers License
x Part
time
Yes Either
x No
If you are 17 years old or
16
younger, enter your age
HOW MANY HOURS CAN YOU WORK PER WEEK?
EDUCATION: Have you graduated from High School or received a High School equivalency diploma?
If No, circle highest grade completed:
Yes x No 1 2 3 4 5 6 7 8 9 10 11 12
SCHOOL
HIGH SCHOOL
NAME
Anywhere High School
ADDRESS
5 School Street Anywhere, CT
01111
DATES ATTENDED
FROM TO
CREDIT HOURS COMPLETED
TYPE OF DEGREE RECEIVED
MAJOR
COURSE OF
STUDY
DID YOU GRADUATE?
2000 Present
--
General
still
--
Studies enrolled
TECHNICAL OR
BUSINESS
COLLEGE OR
UNIVERSITY
HAVE YOU EVER BEEN CONVICTED OF A CRIME?
Yes
x No
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type of rehabilitation.
N/A
Adapted from the Department of Administrative Services, PLD-1, by the Connecticut Department of Labor, 200 Folly Brook Boulevard, Wethersfield, CT 06109
INSTRUCTIONS
Beginning with your PRESENT OR MOST RECENT employment or volunteer experience and working backward, list all positions held which are necessary for determining your eligibility for employment. List all positions (titles) separately; even if with the same employer. Clearly describe the work (duties) you personally performed. You must fill out this application completely even if a resume is being attached.
Official Job title (Start with most recent job)
Company Name
Type of Business
Newspaper Deliverer
The Anywhere Press
Private Sector
Title of Immediate Supervisor
Dept. Where Assigned
Business Address/Phone No.
Sam Circular
Circulation
1 Print Street, Anywhere CT,
987 ? 654 - 1229
Employed From:
(Mo.)
(Yr.)
To: (Mo.)
Total (Yrs. Mos.) Salary or Wage (Yr.)
Hours Per Week
(Full-time)
(Part-time)
6 2000 Present
2 yrs. 6 mos. $ 7.00 Per hour
10
No. and Titles of Employees Supervised by You
Reason for Leaving
0
Still employed
DUTIES (must be listed)
Sort and bundle newspapers for delivery. Hand deliver to 30 customers.
Official Job title (Start with most recent job)
Company Name
Type of Business
Stock Clerk
Anywhere Department Store
Retail Store
Title of Immediate Supervisor
Dept. Where Assigned
Business Address/Phone No.
Mr. Banks
Automotive
14 Main Street, Anywhere, CT 06111
987-654-1546
Employed From:
(Mo.)
(Yr.)
7
01
To: (Mo.)
12
Total (Yrs. Mos.) Salary or Wage
(Yr.) 5 months 01
$ 6.40 Per hour
Hours Per Week
(Full-time)
(Part-time)
10
No. and Titles of Employees Supervised by You
Reason for Leaving
0
Store Closed
DUTIES (must be listed)
Took inventory of items that needed to be re-ordered. Communicated with manager. Priced and
stocked shelves with new items. Helped customers retrieve and carry items.
Official Job title (Start with most recent job)
Company Name
Title of Immediate Supervisor
Dept. Where Assigned
Employed From:
(Mo.)
(Yr.)
To: (Mo.)
Total (Yrs. Mos.) (Yr.)
No. and Titles of Employees Supervised by You
DUTIES (must be listed)
Type of Business
Business Address/Phone No.
Salary or Wage
$
Per
Reason for Leaving
Hours Per Week
(Full-time)
(Part-time)
CERTIFICATION:
I certify that the statements made by me on this application 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.
SIGNED: ___Job L. Application________________________________________
DATE: ___12/30/02____
Adapted from the Department of Administrative Services, PLD-1, by the Connecticut Department of Labor, 200 Folly Brook Boulevard, Wethersfield, CT 06109
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