Fillable Form Cs-9 - Examination Application printable pdf download

CS-9 REV. 6/09

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

DEPARTMENT OF ADMINISTRATION

FOR HUMAN RESOURCES USE

DIVISION OF HUMAN RESOURCES

ONLY

OFFICE OF PERSONNEL ADMINISTRATION

One Capitol Hill

APPLICATION # ______________

TELEPHONE: 222-2172

Providence, Rhode Island 02908-5860

RI RELAY 711

RESIDENCY REQUIREMENT (REF GL 36-4-18)

IMPORTANT:

AN EQUAL OPPORTUNITY EMPLOYER

INSTRUCTIONS: Only that information specifically listed on this application will

DO NOT WRITE IN THIS BLOCK

be considered in determining your qualifications for the examinations for which

SOCIAL SECURITY NUMBER

________________________________________________

FOR OFFICIAL USE ONLY

you have applied. Insufficient information may result in rejection from an

NOTE: Providing your Social Security Number is voluntary in accordance with the Privacy

examination or a lower score on your Education and Experience rating.

VPTS: _______

Init: ______

Act of 1974. Your cooperation is encouraged, as this information is necessary for

The Office of Personnel Administration reserves the right to investigate all

properly crediting you with veteran’s credit or bonus points for determining eligibility for

Prom: _______

Stat: ______

promotional examinations in accordance with State Law.

statements made on your application, and to require proof of such statements

when deemed necessary. Any individual with a disability who requires

NAME________________________________________________________________________

Lang: _____________________

assistance during the exam process should notify the Examination Section 7

FIRST

LAST

Days in advance to ensure that appropriate accommodations will be made.

Class: _____________________

RESIDENCE _________________________________________________________________

Retain a copy of this application for your records, as it will not be returned

MAILING ADDRESS

to you. Attach additional pages if needed.

Base: _____________________

___________________________________________________________________________

PLEASE PRINT OR TYPE ALL INFORMATION LEGIBLY

CITY

STATE

ZIP CODE

Init: _______________________

TELEPHONE _________________________________________________________________

Date: ______________________

HOME

CELL

Serial: _____________________

ONLY

COMPLETE THIS SECTION

IF YOU CLAIM TO BE A

each

List the TITLE AND NUMBER of

exam for which you are applying.

WAR VETERAN.

____________________

_____

1. _______________________________________________

__________

WAR TIME SERVICE DATES APPLICABLE UNDER

RHODE ISLAND LAW (Ref GL 36-4-19):

____________________

_____

2. _______________________________________________

__________

12/7/41 - 12/31/46

8/20/82 - 12/31/87

____________________

_____

6/27/50 -

1/31/55

12/20/89 -

1/31/90

3. _______________________________________________

__________

7/1/58

1/1/59

8/2/90 -

7/13/92

____________________

_____

8/5/64

5/7/75

4. _______________________________________________

__________

If disabled veteran, V.A. Claim Number

: ____________________________________

____________________

_____

5. _______________________________________________

__________

If you claim veteran’s credit, attach a copy of your separation papers (usually Form DD-214)

to this application. If you are also a Disabled Veteran, attach a copy of V.A. Form FL 21-802

____________________

_____

_______________________________________________

__________

(Disabled Veteran’s Preference Form). THE PAPERS WILL NOT BE RETURNED TO YOU.

Only with the required papers will you receive veteran’s service credit.

____________________

_____

CHECK THOSE LANGUAGES IN WHICH YOU ARE FLUENT:

____________________

_____

____ ENGLISH

____ PORTUGUESE

____ SPANISH

____ THAI

____ VIETNAMESE

____ FRENCH

____ HMONG

____ CAMBODIAN

____ ITALIAN

____ LAO

____ SIGN LANGUAGE

____ OTHER (specify) __________________________________________________________________________

NOTE: YOU are responsible for applications sent through the mail.

COMPLETION OF THE SIGNATURE BLOCK IS REQUIRED. UNSIGNED APPLICATIONS WILL BE RETURNED UNPROCESSED.

I certify to the truth and completeness of all statements made on this application. I have read and understand the instructions as specified on this application, and

recognize that any false or deceptive statement or omission of material fact may bar me from examination(s) or may result in my removal from appropriate civil

service lists or my dismissal from State Service.

_________________________________________________________________________________________

___________________

Signature

Date