State Form 22477 - Application For Employment - An Equal Opportunity Employer - 2000
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4TITLE OF POSITION
JOB CODE
APPLICATION FOR EMPLOYMENT
State Form 22477 (R13 / 6-00)
AN EQUAL OPPORTUNITY EMPLOYER
AGENCY NAME
INSTRUCTIONS: 1. Please type or print legibly in black ink.
2. All areas must be completed for consideration.
3. Return completed form to the agency
specified on the Job Bank by the closing
POSTING NUMBER
date.
4. MMDDCCYY stands for month, date ,century and
year.
Applicant Personal Data
Name of applicant (last, first, middle)
(For office use only) Applicant ID
Mailing address (number and street)
City
County
State
Zip Code
Date of Birth (MMDDCCYY) (If under 18 years)
Highest Education Level:
Eligible to work in U.S.
Area code and telephone
Additional Telephone:
Yes
No
(
)
(
)
The State is requesting your Social Security number under authority of IC 4-1-8 to accomplish statutory purposes.
Social Security Number:
Disclosure is mandatory and this form cannot be processed without it.
Job Bank
Internet
Newspaper
Radio
Referral Information: How did you find out about this employment
opportunity with the State of Indiana? Please check appropriate box.
TV
Job Fair
Other
(Please Explain)
Mark type(s) of employment acceptable to you:
Full-time
Part-time
Temporary
Education
List below all high schools and post high schools attended. A copy of applicable transcripts may be required at the time of the interview. (Transcripts and
GED certificate are required for all Indiana State Police positions.)
Number of
To
Number of Semester
Diploma (GED) or
Name/Location of School
From (MO/YR)
Fields of Study
Quarter Hours
(MO/YR)
Hours Completed
type of Degree
Completed
Specialized Training or Classes Relevant to the Job
Title of Specialized Courses
Credits
Company/School
Dates Attended
Earned
Criminal Record
Have you ever been convicted of a crime, other than minor traffic violations?
Notice:
A “yes” response will not necessarily
Yes
No
If yes, provide information regarding the conviction
eliminate you from consideration for
(offense, date, sentence) on a separate, attached sheet.
employment.
Professional Certification
Are you currently certified, registered, or licensed in any profession in
Indiana? (If yes, give complete information, including any license or
Date of issue
Expiration
License or Registration Number
registration number, and attach a copy of certificate if related to the
(MMCCYY)
Date
position for which you are applying).
Yes
No
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