State Of Oklahoma Employment Application

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State of Oklahoma
Office of Personnel Management
Jim Thorpe Memorial Office Building, Room B-22
2101 North Lincoln Boulevard • Oklahoma City, OK 73105
OPM website:
(405) 521-2171 • (405) 521-6314 - TDD Number
(You must have a TDD machine to use the TDD number.)
Please print clearly or type
Please read instructions on page 2 before completing the application
Social Security Number: ____________________________
Date of Application:____________________________
Name: __________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________
Street Address, Apt #
Zip Code
County: _______
E-mail address ___________________________________________________
(Codes on page 2)
Evening Telephone:_____________________________
Day Telephone: _____________________________
(Include area code)
(Include area code)
JOB OR JOB FAMILY DESIRED:______________________________________________________
Indicate the conditions under which you will accept employment (Yes or No - If blank, YES is assumed)
Full-time: ___________ Part-time: ____________
Shift work: ____________
Travel: ____________
(Travel may include regular overnight or across town assignments)
Are you at least 21 years of age?_____ (Yes or No) (Will be used only where age is an approved, bonafide job requirement.)
List the county codes (listed on page 2) for which you wish to be considered for employment. If none are indicated it is assumed
you are willing to work anywhere in the state.
For Office Use Only
JFD Code
JFD Code
The Office of Personnel Management will remove this section
Voluntary Applicant Survey - The information requested will be used to assist state agencies in complying with state and federal record keeping and reporting
requirements. It may be made available to employing agencies when they exercise state laws authorizing affirmative action in hiring. Please provide accurate
information. Your cooperation is important and appreciated. For affirmative action purposes, state law requires any person who lists American Indian as
his/her race or ethnic group to verify tribal affiliation by providing a certificate of Degree of Indian Blood from the U.S. Department of Interior, Bureau of Indian
Affairs, or by providing the name and address of tribal officials who can verify tribal affiliation. Do NOT turn this verification in with this employment application.
It should be turned in to the hiring agency within thirty days of appointment.
Social Security Number:___________________
Sex:______ (M or F)
Race or Ethnic Group (Check only one)
1._____ Black (not of Hispanic origin)
4. _____ Hispanic (Mexican, Puerto Rican, Cuban
2._____ Asian or Pacific Islander
Central or South American or other Spanish
3._____ American Indian or Alaskan Native
culture or origin, regardless of race)
5. _____ White (not of Hispanic origin)
The State of Oklahoma is an Equal Opportunity Employer
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OPM-4 (12/21/04)


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