State Of Connecticut Special Application For Secretary 1 Examination Only

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STATE OF CONNECTICUT
Social Security Number:
-
-
SPECIAL APPLICATION
FOR THE SECRETARY 1 EXAMINATION ONLY (CT-HR-20)
DO NOT WRITE
APPROVED________
DISAPPROVED________
REVIEWED BY: __________
in shaded area
GE – Lack GE
LG – Length GE
CS – Status in Class
LT – Late
Instructions: This special application form is to be used to apply for the State of Connecticut Secretary 1 examination only. (The
CT-HR-12 or other application forms will not be accepted.) Application forms will be accepted from September 18, 2015 through
October 2, 2015 at 5:00 PM EST. Applications received by the Department of Administrative Services (DAS), Statewide Human
Resources Management Division after 5:00 PM EST on October 2, 2015 or applications received on other forms will not be accepted.
Complete all parts of the application form. If you are claiming veteran’s credit, attach form CT-HR-19. Do not attach resumes or any
other forms or documents with your application form. Applications should be faxed to 860-706-1494 or 860-706-1495 or hand delivered
to Room 404, 165 Capitol Avenue, Hartford CT, 06106. It is not recommended that you mail your application form as you cannot ensure
it will be received on time.
EXAMINATION TITLE: Secretary 1
EXAM NO. 042790,0010
NAME (Last)
(First)
(M)
SUFFIX (Jr., Dr.)
ADDRESS (Number and Street)
CITY
STATE
ZIP CODE (Last 4 digits are optional)
HOME PHONE NUMBER
BUSINESS PHONE NUMBER
CELL PHONE NUMBER
E-mail address:
Are you currently employed by the State of Connecticut?
Voluntary:
In order to meet State and Federal reporting requirements, we are
requesting that you voluntarily supply the following information. This data will not be
Yes
No
used for discriminatory purposes and will not be considered in the evaluation of your
application.
If yes:
Emp. ID: ____________________________
Sex:
Female
Male
Job Title: _____________________________________
RACE/ETHNIC DATA
B- BLACK/AFRICAN AMERICAN
W -WHITE (not of Hispanic Origin):
(not of Hispanic Origin)
What kind of
Full
Part
Either
Position are you
time
time
H- HISPANIC:
A -ASIAN OR PACIFIC ISLANDER
applying for?
I - AMERICAN INDIAN OR ALASKAN NATIVE
EMPLOYMENT DISTRICTS
Check the box(es) for ONLY the district(s) in which you will accept employment. Not all jobs are used in all locations. Names will be certified by location.
Location preferences may be changed by submitting a written request to DAS/Statewide Human Resources Management.
A - All Locations
O - Avon, Farmington, West Hartford
B - Greenwich, Stamford, New Canaan, Darien
P - East Hartford, Manchester
C - Norwalk, Wilton, Weston, Westport
Q - Hartford
D - Fairfield, Easton, Monroe, Trumbull, Shelton, Stratford
R - Granby, Canton, Simsbury, Suffield, East Granby, Windsor Locks,
Windsor, Bloomfield, East Windsor, South Windsor, Ellington, Vernon,
E - Bridgeport
Tolland, Stafford, Willington
F - Redding, Ridgefield, Danbury, Bethel, Newtown,
S - Enfield, Somers
Brookfield, New Fairfield, Bridgewater, Sherman,
T - Newington
New Milford, Roxbury, Washington, Kent, Warren
G - Morris, Litchfield, Harwinton, New Hartford,
Torrington, Goshen, Cornwall, Sharon, Salisbury,
U - Union, Ashford, Mansfield, Chaplin, Hampton, Windham, Scotland,
Canaan, North Canaan, Norfolk, Colebrook,
Lebanon
Winchester, Hartland, Barkhamsted
H - Thomaston, Bethlehem, Watertown, Woodbury,
V - Cromwell, Portland, Middletown, Middlefield, Durham, East Hampton,
Southbury, Middlebury, Beacon Falls, Naugatuck,
Haddam, East Haddam, Chester, Essex, Killingworth, Deep River,
Prospect, Waterbury, Wolcott, Cheshire
Westbrook, Old Saybrook
W- Lyme, Old Lyme, East Lyme, Salem, Montville, Waterford, New London,
I - Oxford, Seymour, Ansonia, Derby
Ledyard, Groton, Stonington, North Stonington
J - West Haven, Orange, Woodbridge, Bethany, Hamden,
X - Bozrah, Franklin, Norwich, Sprague, Lisbon, Preston, Griswold, Voluntown
North Haven, East Haven
K - New Haven
Y - Woodstock, Thompson, Putnam, Pomfret, Eastford, Brooklyn, Canterbury,
L - Meriden
Plainfield, Sterling, Killingly
M - Plymouth, Bristol, Burlington
Z - Glastonbury, Marlborough, Colchester, Hebron, Columbia, Andover,
Bolton, Coventry
N - Berlin, Southington, Plainville, New Britain
Page 1

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