EMPLOYMENT APPLICATION CRIMINAL HISTORY RECORD JD-ES-11A Rev. 3/08 C.G.S. § 31-51i STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov INSTRUCTIONS: 1. Type or print in ink, answer all questions completely. 2. Return with completed Employment Application form (JD-ES-11) 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 NAME OF APPLICANT (Last, first, middle) HOME PHONE (with area code) BUSINESS PHONE (with area code) NAME AND ADDRESS ADDRESS Have you ever been convicted of a criminal offense or an offense against military law? (SEE NOTICE BELOW) (Exclude minor traffic violations or any offense settled in a juvenile court or under a YES NO youthful offender law.) IF YES, GIVE DETAILS (Use additional sheet if necessary) DETAILS CONTINUED ON BACK / NEXT PAGE (1) You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to C.G.S. §§ 46b-146, 54-76o or 54-142a, NOTICE (2) criminal records subject to erasure pursuant to C.G.S. §§ 46b-146, 54-76o or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon, and (3) any person whose criminal records have been erased pursuant to C.G.S. §§ 46b-146, 54-76o or 54-142a shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath. 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) DATE SIGNED MUST be completed and returned with Employment Application (Form JD-ES-11). American LegalNet, Inc. www.FormsWorkflow.com NAME OF APPLICANT (Last, first, middle) DETAILS (Continued from previous page): DETAILS (Continued) JD-ES-11A (Page 2) Rev. 3/08 EQUAL OPPORTUNITY EMPLOYER American LegalNet, Inc. www.FormsWorkflow.com