(Page 1 of 7)CERTIFICATE OF EMPLOYABILITY APPLICATION - CSSD JD-AP-187 Rev. 2-19 C.G.S. 247 54-130eSTATE OF CONNECTICUT JUDICIAL BRANCH COURT SUPPORT SERVICES DIVISION Section 1: Applicant Information Last name First name Date of birth ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Application for Certificate of Employability Middle name Social security number Place of birth Gender Address (Number and street) Apartment number/floor City State Zip code Home phone number Business phone number Cell phone number E-mail address Section 2: Family InformationPlease list all members of your household (anyone who lives with you) below: Name Age Relationship to you 1. 2. 3. 4. 5. How long have you lived at your current address? Current spouse/partner's name: Current marital status? Single Married Divorced Separated Widow Widower Civil unionState, in full, every other name by which you have been known, including the reason for your use of another name, and the dates during which you were so known (for example, include your maiden name, name by a former marriage, aliases, and nicknames). Section 3: Alias and Other Names1.2.3. Section 4: Previous Application HistoryHave you applied for a Certificate of Employability or Provisional Pardon in the past? Yes NoIf yes, please state the month(s) and year(s) you applied: Section 5: Citizenship InformationAre you a citizen of the United States of America? Yes NoIf you answered no, country of citizenship: Instructions to applicant: Fill out this application and return it with the other required documents to the CSSD Certificate Review Unit. See Page 7 of this application for detailed instructions on how to fill out the application and where to send it. American LegalNet, Inc. www.FormsWorkFlow.com (Page 2 of 7) Section 6: Education Background/Special TrainingPlease check the highest grade you finished:Please list any education or other special training you have gotten or are currently getting. Include the school name, dates that you went there, degrees that you earned, and any honors that you got. If you went to training, list the type of training and the agency that provided the training. You should attach a copy of any certificates, diplomas, or transcripts that you got to this application. Section 7: Employment HistoryList your jobs and employers for the last 5 years or since you left school, whichever period is less. Do not leave out or skip any jobs. Start with the job that you have now or your most recent job and work back. Dates (month & year) Job/position Employer name/address/phone number 1. 2. 3. 4. 5. 6. Supervisor Licenses/certifications held Type of license Licensing agency License number 1. 2. 3. Date issued Expires Section 8: Military HistoryWhere you ever in any branch of the U.S. Armed Forces? Yes NoIf yes, please answer below: Branch of service Date of entry into active duty Date of dischargeDid you serve in the National Guard? Yes No Type of discharge Rank at dischargeAttach a copy of your separation papers (Form DD-214) or your military ID (DD Form 2) if you are currently active. Section 9: Criminal HistoryConviction Record - You must list all of your convictions, including convictions in Connecticut and in any other state and federal convictions. Any willful omission (leaving anything out on purpose) will be construed as a false statement (lying) and might cause your application to be denied. Dates Court and location Charge Sentence If you would like to get an official transcript of your criminal history to help you in filling out this section of the application, you can get one from the Connecticut State Police for a fee of $50 and attach it to this application. http://www.ct.gov/despp/lib/despp/reportsandrecords/ dps-846-c.pdf 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24+ American LegalNet, Inc. www.FormsWorkFlow.com (Page 3 of 7) Section 10: Victim InformationPlease list the name(s) and approximate age of any victim(s) of your crime(s) and their phone number(s) or address(es) if you know this information. DO NOT try to get in touch with any victim. If there was no victim to your crime(s) or you do not know the name of your victim(s), please write 223No victim.224 or 223Victim information unknown.224 The Certificate Review Unit will still review your application if you do not know the information about any victims of your crime(s). State your reason(s) for applying for a Certificate of Employability Section 11: Purpose of Application In your own words, how have you changed since your criminal activity? You may also use this section to tell the Certificate Review Unit about anything else that you would like it to think about as part of your application. Attach additional sheet(s) if necessary. American LegalNet, Inc. www.FormsWorkFlow.com (Page 4 of 7)Please use this section to complete any information that you could not fit on the application Section 12: Optional Continuation PagePlease Number The Section That You Are Continuing Section number Response Section number Response Section number Response Section number Response Section number Response American LegalNet, Inc. www.FormsWorkFlow.com (Page 5 of 7)I, , agree to allow an investigation to be made to determine my fitness for a Certificate of Employability pursuant to No. 14-27 of the 2014 Public Acts. I hereby state, under penalty of false statement, that I have, to the best of my ability, fully and truthfully answered all of the questions in this application. Section 13: Attestation and Background Investigation Authorization Applicant's signature DateSubscribed and Sworn before me this day of , 20 Signature of Notary PublicMy commission expires on Notary sealI, , have applied to the State of Connecticut Judicial Branch Court Support Services Division Certificate Review Unit for a Certificate of Employability. To facilitate the investigation of my application, I hereby authorize any individual, private business concern, state or federal agency to release any information such person, private business concern, state or federal agency may have in its possession concerning me or my activities. Applicant's signature Date American LegalNet, Inc. www.FormsWorkFlow.com (Page 6 of 7) Statistical and Research Information SheetThis section is optional and will be used for research and statistical purposes onlyThis section will not be given to any Probation Certificate Review Unit members Full name Phone number Address Email addressRace/Ethnic Data BLACK (not of Hispanic Origin); Person having origins in any of the Black racial groups of Africa. HISPANIC: Persons of Mexican, Puerto Rican, Central or South America or other Spanish culture or origin, regardless of race WHITE: (not of Hispanic Origin): Person having origins in any of the original peoples of Europe, North Africa, or the Middle East. AMERICAN INDIAN OR ALASKAN NATIVE: Persons having origin in any of the original peoples of North America who maintain cultural identification through trial affiliation or community recognition OTHER: (Please specify) - ASIAN OR PACIFIC ISLANDER: Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa May we contact you in the future for research purposes? Yes NoFuture Studies American LegalNet, Inc. www.FormsWorkFlow.com (Page 7 of 7)INSTRUCTIONS FOR COMPLETING A CERTIFICATE OF EMPLOYABILITY APPLICATIONELIGIBILITYThis application is for individuals on Adult Probation as a result of a criminal conviction and individuals who have at least one prior conviction and who are currently being supervised by the Court Support Services Division (CSSD). A Certificate of Employability is for employment purposes only and does not erase your criminal history. You can only apply for a Certificate of Employability with CSSD if you are currently on probation or you are currently