Fillable Provisional Appointment Request Form (Per-4) printable pdf download

State of Connecticut Human Resources

Provisional Appointment Request Form

Form #: PER-4

Revision Date: 02/2016

Agency __________________________________________________________________________________

Location of position: Facility/Dept _____________________________ Town/City _____________________

Full or part time ____________________________ Number of hours per week ________________________

Class Title __________________________________________________ Class Code ___________________

Section 5-235(a) of the Connecticut General Statutes states: When a candidate list provided under section 5-215a

contains fewer than five candidates, in order to facilitate the carrying on of public business or avoid inconvenience to the

public, but not otherwise, the Commissioner of Administrative Services may authorize the filling of the position at once by

provisional appointment, pending the establishment of a reemployment or candidate list.

Any such provisional

appointment shall continue only until a reemployment or candidate list for such position is established and, in no case, for

a period exceeding a total of six months. No person shall receive more than one provisional appointment or serve more

than six months as a provisional appointee in any one fiscal year.

A. RECLASSIFICATION OR VACANT POSITION

Is this a reclassification of a filled position?

Yes

If yes, skip to Section D. If no, complete all sections on the form. (A provisional appointment is not needed

if the appointment is being made to an unclassified or noncompetitive class or if all of the criteria of Section

5-227a are met.)

B. REPORT ON CURRENT LISTS

Is a reemployment list available?

Yes

Date checked on APS _____________

Is a SEBAC list available?

Yes

Date checked on APS _____________

Note:

It is the agency’s responsibility to check reemployment lists immediately prior to offering an

appointment. Agencies must also recheck SEBAC lists prior to offering an appointment if more than 21

calendar days have elapsed since the initial list was requested.

If you answered yes to either of the above questions, documentation must be provided supporting the contact

of the individuals on the list(s) and their waiver(s) of the position. Copies of the list(s) must be attached.

Explanation:

______________________________________________________________________________________________

Is there a candidate list available?

Yes

Date checked on APS __________

If yes, how many names appear on the list? _________

If yes, detail the reasons why the candidate(s) on the list cannot meet the requirements of the position.

(Documentation must be provided supporting the contact of the individuals on the lists and their waiver(s) of

the position. Copies of the list must be attached.)

_______________________________________________________________________________________________

This form provided by the Department of Administrative Services

Provisional Appointment Request Form (Per-4)

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