Employment Application - Kansas Department Of Administration Page 4

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Other Employment: (Account for all employment in at least the last 10 years)

Name and Address of Company

Position Held

Employment Dates

Other Related Experiences: Please describe here any other related professional certifications, honors, special skills, qualifications, or

experiences not mentioned elsewhere, i.e., equipment or machines operated, etc.

Computer Skills (name software and hardware) __ ___________________________________________________________________________

___________________________________________________________________________________________________________________

SUPPLEMENTAL WORK EXPERIENCE _______________________________________________________________________________

___________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

References Include supervisors and persons we may contact to verify your performance and qualifications.

Name

Occupation

Mailing Address

Organization

Your supervisor?

Yes

Phone (Day)

Name

Occupation

Mailing Address

Organization

Your supervisor?

Yes

Phone (Day)

Name

Occupation

Mailing Address

Organization

Your supervisor?

Yes

Phone (Day)

AFFIRMATION

I affirm that the facts set forth above in my application for employment are true, correct and complete to the best of my knowledge. I understand

that I may be required to submit information not requested on this application form; that the employing agency may verify any information

provided by me in the employment process; and that incomplete information or omission of my signature is just cause for rejection of my

application.

I understand and agree that, if hired, my employment would be contingent upon conditions specific to the position for which I am applying. I also

understand that any omission of information, or erroneous information provided in any part of the employment process, would be sufficient

cause for discharge. I agree that the employing agency may, at its sole discretion, provide compensatory time off in lieu of overtime pay if I were

employed in a nonexempt position and if there were no existing agreement to the contrary.

SIGNATURE OF APPLICANT

DATE

If you are applying for a vacancy which has a requisition number (Req No), you must also register using the Personal Data form, if you have not already done so.

Personal Data forms are available from any state agency or Workforce Center. Return this application form to the agency which has the vacancy for which you are

applying; do not return this form to any other location. For general information about the State of Kansas employment process, phone Civil Service Employment

Information (Department of Administration, Topeka, Kansas) at 785-296-4278.

THE STATE OF KANSAS IS AN EQUAL OPPORTUNITY EMPLOYER

Promoting Diversity in a Diverse State

DA 215 – Rev. 8/11