Instructions For Completing And Submitting The State Of Connecticut Application For Examination Or Employment (Form Ct-Hr-12) (Fillible) Page 2
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12APPLICATION FOR EXAMINATION
SOCIAL SECURITY NUMBER: ____ ____ ____ -____ ____ - ____ ____ ____ ____
OR EMPLOYMENT CT-HR-12 NEW 10/20/2010
(formerly Form PLD-1)
________________________________________
_______________________ ____
Last Name
First Name
MI
STATE OF CONNECTICUT
Application for Examination or Employment (CT-HR-12)
DO NOT WRITE
APPROVED________
DISAPPROVED________
REVIEWED BY: __________
AE Date: __________
in shaded area
GE – Lack GE
LS – Length SE
GS – Length GE, Lack SE
AS – No Agency Status
SI – No Supp Exam Mat.
LG – Length GE
ET – Lack GE, SE
EM – Not Current St Emp
ST – No Classified Status
II – Insufficient Info
SE – Lack SE
LL – Length GE, SE
AR – Emp not Hiring Agency
CS – Status in Class
LT – Late
INSTRUCTIONS TO APPLICANT: Read the detailed instructions on the first page of this application
and on the examination announcement or position/job posting before completing this application form.
Type or print answers to ALL questions.
SECTION 1: APPLICANT CONTACT INFORMATION
______________________________
_____________________
___
______
LAST NAME
FIRST NAME
MI
SUFFIX
(i.e., Jr., MD, Ph.D.)
_________________________________________________________
____________________
MAILING ADDRESS (P.O. Box # or house number and street)
APARTMENT # (if any)
_______________________________________________
______
_________________
CITY
STATE
ZIP CODE
List other name(s) you have used. Include last name, first name and middle initial for each.
_____________________________________
______________________________________
(____)______-________
(____)______-________
May we call you at work? __Yes __No
HOME PHONE #
BUSINESS PHONE #
(____)______-________
_______________________________________________
CELL PHONE #
E-MAIL ADDRESS
SECTION 2: PURPOSE OF APPLICATION (CHECK ONE):
___ STATE EXAMINATION
___ STATE POSITION/JOB POSTING
Complete the required information below for one examination OR one position ONLY:
If you are applying for a State of Connecticut examination complete the following information as it
appears on the examination announcement:
Examination Title: ___________________________________________ Exam No.: _____________
OR
If you are applying for a State of Connecticut position/job complete the following information as it
appears on the posting.
Position/Job Title: ______________________________________ Job Posting No.: ___________
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