Instructions For Completing And Submitting The State Of Connecticut Application For Examination Or Employment (Form Ct-Hr-12) (Fillible) Page 5
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12PAGE FOUR
________________________________________
_______________________ ____
Last Name
First Name
MI
______________________________________________________________________
Examination Title or Position Title
SECTION 5: APPLICANT EDUCATION (continued)
C. Technical, Business or Other Education
1.) ______________________________________ ______________________ ___
__________
Name of School Attended
City
State
Country*
Dates of Attendance: From: _____/_____To:_____ _____
/
________________________________
(MM/YYYY)
(MM/YYYY)
Type of degree or certificate earned
2.) ______________________________________ ______________________ ___
__________
Name of School Attended
City
State
Country*
Dates of Attendance: From: _____/_____To:_____ _____
/
________________________________
(MM/YYYY)
(MM/YYYY)
Type of degree or certificate earned
SECTION 6: R EQUIRED LICENSES, CERTIFICATIONS AND OTHER
1. Do you have any valid licenses or certificates which authorize you to practice a profession or trade? (e.g.
law, nursing, psychology, plumbing, etc.) ___Yes
___No
If yes, please complete the following section:
A.) Type of License: ________________ License #: ____________ Issued By: ___________
Date Issued: ____/____
Expiration Date: ____/____
(MM/YY)
(MM/YY)
B.) Type of License: ________________ License #: ____________ Issued By: ___________
Date Issued: _ ___/____
Expiration Date: ____/____
(MM/YY)
(MM/YY)
2. Do you currently have a valid Motor Vehicle Driver’s License (Class D)? __
Yes
__
No
State:
______
3. Do you have any endorsements to your Class D license? If so which ones? __________________
4. Do you currently have a valid Commercial Driver’s License (CDL)? __Yes __No
State:
_______
If you have a CDL what class?
____Class A
____
Class B
___
_Class C
5. What languages do you speak, read, write or sign fluently? _______________________________
_____________________________________________________________________________________
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