EMPLOYMENT APPLICATION STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov JD-ES-11 Rev. 3/08 C.G.S. § 31-51i INSTRUCTIONS: 1. Type or print in ink, answer all questions completely. 2. Form JD-ES-11A MUST be completed and returned with this form to: Judicial Branch, Human Resource Management Unit, 90 Washington St., Hartford, CT 06106 AN EQUAL OPPORTUNITY AFFIRMATIVE ACTION EMPLOYER This application may be made available in an alternate format upon request by a qualified individual with a disability under the provisions of the Americans with Disabilities Act. If you need assistance, please contact the Recruitment Section of the Human Resource Management Unit at (860)706-5288. POSITION(S) APPLYING FOR DATE OF APPLICATION HOME PHONE (with area code) NAME OF APPLICANT (Last, first, middle) BUSINESS PHONE (with area code) NAME AND ADDRESS ADDRESS NAME OF HIGH SCHOOL CITY AND STATE "X" here if you are a high school graduate or have received an equivalency diploma. Please list all schools you have attended since high school. (Technical, Business, College, or other) NAME OF SCHOOL CITY AND STATE MAJOR SUBJECT DID YOU GRADUATE? DEGREE RECEIVED EDUCATION List here only the employment that you believe qualifies you for the position(s) you are applying for. List all other experience in the next section. Begin with PRESENT or MOST RECENT employment and work backwards. If additional space is required, attach an additional sheet using the same format. 1 NAME AND ADDRESS OF EMPLOYER (City and state) TELEPHONE (with area code) SALARY OR WAGE $ JOB TITLE NAME OF IMMEDIATE SUPERVISOR HOURS PER WEEK EMPLOYED FROM (Mo , yr ) TO (Mo., yr ) TOTAL (Years, months) PER DUTIES (Include knowledge, skills and abilities required) 2 NAME AND ADDRESS OF EMPLOYER (City and state) TELEPHONE (with area code) EXPERIENCE SALARY OR WAGE $ JOB TITLE NAME OF IMMEDIATE SUPERVISOR HOURS PER WEEK EMPLOYED FROM (Mo , yr ) TO (Mo., yr ) TOTAL (Years, months) PER DUTIES (Include knowledge, skills and abilities required) 3 NAME AND ADDRESS OF EMPLOYER (City and state) TELEPHONE (with area code) SALARY OR WAGE $ JOB TITLE NAME OF IMMEDIATE SUPERVISOR HOURS PER WEEK EMPLOYED FROM (Mo , yr ) TO (Mo., yr ) TOTAL (Years, months) PER DUTIES (Include knowledge, skills and abilities required) CONTINUED ON PAGE 2 American LegalNet, Inc. www.FormsWorkflow.com List all other experience. Account for all time since school. DATE (Mo., Yr.) FROM TO NAME OF EMPLOYER ADDRESS (City, State) JOB TITLE SALARY GENERAL EXPERIENCE List relevant knowledge, skills and abilities you have acquired in the above employment. OTHER KNOWLEDGE, SKILLS AND ABILITIES 1. Have you ever been discharged from a job? YES NO YES NO YES NO IF YES, PLEASE EXPLAIN 2. May we contact your present and past employers for information about your duties? ADDITIONAL IF NO, PLEASE EXPLAIN INFORMATION 3. Have you ever worked for another branch of government or state agency? IF YES, INDICATE WHICH OFFICE(S) AND DATES OF EMPLOYMENT (If not indicated above) List here any licenses or certificates you may hold, which are valid and in good standing. NAME OR DESCRIPTION ISSUED BY NUMBER DATE LICENSES AND CERTIFICATES CERTIFICATION I certify that the statements made by me on this application are COMPLETE and TRUE to the best of my knowledge and belief and are made in good faith and I have not withheld pertinent information. I understand that if I knowingly make any misstatement of facts, I am subject to disqualification or dismissal and to such other penalties as may be prescribed by law or Judicial Branch policies. I also understand that application and appointment to a temporary position is no guarantee of appointment to a permanent position. Read this application and your answers CAREFULLY before signing. SIGNED (Applicant) IMPORTANT NOTICE DATE SIGNED All offers of employment are contingent on the production of proper documents verifying your eligibility for employment pursuant to the Immigration Reform and Control Act, a federal law. You will be required to produce these documents within the first three days of employment. At your request, the interviewer will inform you concerning the type of documents that will be required. You may also be subject to a criminal history background check. JD-ES-11 (Page 2) Rev. 3/08 Form JD-ES-11A MUST be completed and returned with this form. American LegalNet, Inc. www.FormsWorkflow.com