Application For Temporary Employment Page 2
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1
2Last Name
First Name
Date
Position 2:
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:
PROVIDE A DESCRIPTION OF VOLUNTEER EXPERIENCE THAT WOULD BE OF PARTICULAR VALUE FOR THIS
POSITION:
APPLICANT CERTIFICATION:
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.
TO REQUEST AN ACCOMMODATION:
Qualified individuals with a disability may request an accommodation in the application process and/or during the interview under the provisions of the
Americans with Disabilities Act (ADA) by contacting ADA Coordinator in the Human Resources Office at 860-297-5700. Please provide a description
of your specific needs.
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 considered in the evaluation of your application.
A.
SEX:
Female
Male
B.
RACE/ETHNIC DATA:
AMERICAN INDIAN OR ALASKAN NATIVE: Persons having origins in any of the original peoples of North America, and who maintain
cultural identification through tribal affiliation or community recognition.
ASIAN OR PACIFIC ISLANDER: Persons having origins in any of the original peoples of the Far East, Southeast Asia, Indian
Subcontinent or the Pacific Islands. This area includes, for example, China, Japan, Korea, Philippine Islands and Samoa.
BLACK/AFRICAN-AMERICAN (NOT OF HISPANIC ORIGIN): Persons having origins in any of the black racial groups of Africa
HISPANIC: Persons of Mexican, Puerto Rican, Central or South American or other Spanish culture or origin, regardless of race.
WHITE (NOT OF HISPANIC ORIGIN): Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
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Parent category: Financial