Fillable Ct-Hr-5 - Placement On Statewide Transfer List Request Form printable pdf download

State of Connecticut

Placement On Statewide Transfer List Request Form

Form #: CT-HR-5

Revision Date: 9/2011

DAS – Statewide Human Resources Management – 165 Capitol Avenue – Room 404 – Hartford, CT 06106

TO:

ATTN: Vickey McCray (Fax# 860-622-2886 or e-mail Vickey.McCray@CT.GOV)

State employees may request to be placed on the statewide transfer list for their present job class if permanent status has been attained.

NOTE: Transfer lists are not maintained by DAS for any Clerical or Health Care Non-Professional bargaining unit positions

or for any unclassified positions.

Procedure: Eligible employee completes the “Employee” section of the form and checks desired location (s) on next page, and signs

the form to authorize their request for transfer. The employee then submits the form in its entirety to DAS-Statewide Human

Resources Management for review and processing. Once approved, the original request is retained in the DAS-Statewide Human

Resources Management files. An approved copy will be returned to the employee at the Home Address listed below.

IMPORTANT: Please check the

DAS Website - State Employment Page

to find out about and to apply for vacancies in State

agencies, universities and colleges. Indicate you are on the Statewide Transfer List when you submit your application material.

THIS SECTION IS TO BE COMPLETED BY THE EMPLOYEE

I request placement on the Statewide Transfer List.

Name:

___________________________________________________________________

Home Address:

___________________________________________________________________

Current Agency:

___________________________________________________________________

Phone Number during the day:

(_________) __________-______________ (include area code)

Social Security Number:

___________________________________________________________________

Employee ID Number:

___________________________________________________________________

Employee’s Class Title:

___________________________________________________________________

I am interested in transferring to the location (s) identified on Page Two of this form.

____________________________________

____________

Signature of Employee Requesting Transfer

Date

THIS SECTION FOR DAS-STATEWIDE HUMAN RESOURCES MANAGEMENT USE ONLY

Class code: _________________

Salary Group: ________________ Bargaining Unit: ___________________

In accordance with your request, your name has been added to the Statewide Transfer List for the following class:

________________________________________________________________________________________________________

Your name will remain on this list for a period of two years unless you request that it be removed or unless you have submitted

another request at the expiration of two years.

_____/_____/_____

___________________________________________

______________

Effective Date

Expiration Date

DAS-Statewide HR Management Representative

Date

This form provided by the Department of Administrative Services

Ct-Hr-5 - Placement On Statewide Transfer List Request Form

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