Application For Temporary Employment
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1
2APPLICATION FOR TEMPORARY EMPLOYMENT
Submit
STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
Print
450 COLUMBUS BLVD
Reset
HARTFORD, CT 06103
Save As
An Affirmative Action/Equal Employment Opportunity Employer
1.
Type or print (in ink) all information requested on the application form. It is critical that you complete all sections of the application form and that all
of the information you provide is true and accurate. You must fill out this application completely even if a resume is being attached.
IF THIS APPLICATION IS NOT COMPLETED IN FULL, WE WILL NOT CONSIDER YOU FOR AN INTERVIEW.
2.
If you are contacted for an interview, you will be expected to provide DRS with letters of reference from previous employers.
3.
Completely fill in the employment history portion with company names and addresses, supervisor names and phone numbers and the dates of your
employment.
4.
Even though not required, the addition of a RESUME is preferred
NAME
Last
First
Middle Initial
Date:
No. and Street
City or Town
State
Zip Code
ADDRESS
Business Phone Number:
Home Phone Number:
Cell Phone Number:
Email Address:
Are you presently employed by the State of Connecticut?
If “yes” your Job Title
Yes
No
Were you ever employed by the State of Connecticut?
If “yes” when and where
Yes
No
Have you used other names in previous jobs?
If “yes,” specify
Yes
No
Can you travel if the job requires it?
Yes
No
Are you under the age of 17?
Yes
No
Do you have any valid licenses or certificates which
Type:
Issued by:
Yes
No
authorize you to practice a profession or a trade?
Date:
No.
INDICATE SKILLS YOU HAVE BY CHECKING ALL APPROPRIATE BELOW:
Spreadsheets: Excel
Encoder
S/HR:
Languages other than English
Databases: Access
Data Entry S/HR:
Please specify
I am proficient in the following Software
speak fluently
Applications
write fluently
APPLICANT EDUCATION
:
Have you graduated from high school or received a high school equivalency diploma (GED)?
Yes
No
What is the highest level of education you have completed:
Name of institution
Associates
Bachelors
Masters
Doctorate
Law
None
If None, please indicate the number of credit hours completed
EMPLOYMENT HISTORY (Additional pages may be added if needed for further employment history. Although not required, a
Resume is the preferred method of additional employment history)
Position 1:
Name of Employer:
Address:
Telephone Number:
Name and Title of Supervisor:
Employed from: (Mo./Yr.)
Employed to: (Mo./Yr.)
.
Your Job Title:
Salary:
Hours per week:
Reason For Leaving:
Description of Duties and Responsibilities:
Revised 9/20/2016
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