Instructions For Completing And Submitting The State Of Connecticut Application For Examination Or Employment (Form Ct-Hr-12) (Fillible) Page 3
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12PAGE TWO
________________________________________
_______________________ ____
Last Name
First Name
MI
______________________________________________________________________
Examination Title or Position Title
SECTION 3 APPLICANT CERTIFICATION
SIGNATURE REQUIRED: By signing or typing my name on the signature line below, I am certifying
that the statements made by me on this application form and attachments, if any, are true and
complete to the best of my knowledge and are made in good faith. I understand that if I knowingly
make any misstatement of fact, I am subject to disqualification and dismissal and to such other
penalties as may be prescribed by law or personnel regulations.
All statements made on this
application, including employment information, are subject to verification as a condition of
employment.
Applicant signature: __________________________________
Date: ____________
(Signature is required)
Note: A typed name will substitute for a handwritten signature.
SECTION 4: STATE EMPLOYMENT HISTORY
(To be completed by current or former State of CT
employees)
Are you a current State of Connecticut employee? __Yes
__No If ‘Yes: __________________
6-digit Employee ID #
_____________________________________
_________________________________________
Official Job Class Title
Employing Agency, Department, College/University
If you are not a current State of Connecticut employee but worked for the State of Connecticut
previously, did you leave State service within the past 10 years? __Yes
__No
If ‘Yes’ complete dates of employment from: ____/____/_______to ____/____/_______
MM DD
YYYY
MM
DD
YYYY
_____________________________________
_________________________________________
Official Job Class Title at time of separation
Employing Agency, Department, College/University
Reason for leaving: ________________________________________________________________
SECTION 5: APPLICANT EDUCATION
A. Primary and Secondary Education
Have you graduated from high school or received a high school equivalency diploma (GED)?
__Yes
__No
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