Fillable Printable Application for Employment Form - Oklahoma

Application for Employment Form - Oklahoma

State of Oklahoma

EMPLOYMENT APPLICATION

Office of Personnel Management

Jim Thorpe Memorial Office Building, Room B-22

2101 North Lincoln Boulevard • Oklahoma City, OK 73105 OPM website: www.opm.state.ok.us

(405) 521-2171 • (405) 521-6314 - TDD Number (You must have a TDD machine to use the TDD number.)

Please print clearly or type

Please read instructions on page 2 before completing the application

Social Security Number: ____________________________ Date of Application:____________________________

Name: __________________________________________________________________________________________

Last First Middle

Mailing Address: __________________________________________________________________________________

Street Address, Apt # City State Zip Code

County: _______

(Codes on page 2)

E-mail address ___________________________________________________

Evening Telephone:_____________________________ Day Telephone: _____________________________

(Include area code)

JOB OR JOB FAMILY DESIRED:______________________________________________________

Indicate the conditions under which you will accept employment (Yes or No - If blank, YES is assumed)

Full-time: ___________ Part-time: ____________ Shift work: ____________

Travel: ____________ (Travel may include regular overnight or across town assignments)

Are you at least 21 years of age?_____ (Yes or No) (Will be used only where age is an approved, bonafide job requirement.)

List the county codes (listed on page 2) for which you wish to be considered for employment. If none are indicated it is assumed

you are willing to work anywhere in the state.

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

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For Office Use Only

JFD Code A/R Code Score Initial/Date JFD Code A/R Code Score Initial/Date

The Office of Personnel Management will remove this section

Voluntary Applicant Survey - The information requested will be used to assist state agencies in complying with state and federal record keeping and reporting

requirements. It may be made available to employing agencies when they exercise state laws authorizing affirmative action in hiring. Please provide accurate

information. Your cooperation is important and appreciated. For affirmative action purposes, state law requires any person who lists American Indian as

his/her race or ethnic group to verify tribal affiliation by providing a certificate of Degree of Indian Blood from the U.S. Department of Interior, Bureau of Indian

Affairs, or by providing the name and address of tribal officials who can verify tribal affiliation. Do NOT turn this verification in with this employment application.

It should be turned in to the hiring agency within thirty days of appointment.

Social Security Number:___________________ Sex:______ (M or F)

Race or Ethnic Group (Check only one)

1._____ Black (not of Hispanic origin)

2._____ Asian or Pacific Islander

3._____ American Indian or Alaskan Native

4. _____ Hispanic (Mexican, Puerto Rican, Cuban

Central or South American or other Spanish

culture or origin, regardless of race)

5. _____ White (not of Hispanic origin)

The State of Oklahoma is an Equal Opportunity Em ployer

OPM-4 (12/21/04) Page 1 of 4

Page 2 of 4

Employment Application Instructions

1. Answer all questions completely, as your score may be

based on a rating of this application. Be sure you have

all 4 pages for the application. Additional sheets may

be attached if necessary.

2. You may apply for one Job Family only per application.

Applications will only be processed for jobs and job

families currently announced for recruitment.

Applications for job families that are

not announced will

be returned to you. It is your responsibility to keep

current on positions announced for recruitment. This

information is on the OPM Recruitment Notice each

week, the OPM web site (address given on page 1 of

application), and at state agencies.

3. If you wish to claim veteran’s preference, complete form

OPM-75 and return it to the Office of Personnel

Management with the required proof.

4. The examinations are administered at the Office of

Personnel Management in Oklahoma City Monday –

Thursday from 9:00 a.m. to 4:45 p.m. or at the local

Career Technology Centers (listed below).

5. If you require special testing due to a disability, please

contact OPM to make arrangements. Persons with

disabilities may wish to request information on the

“Persons with Severe Disabilities” Employment

Program.

6. Applicant information will be entered into a computer

and all materials, including transcripts, will be available

to state agencies. If you get a state job, your file is

open to public inspection except for certain information

specifically required by law to be kept confidential. All

information provided during the application process is

subject to investigation and verification. Also, a

personal background investigation, including any

civilian or military court records, may be conducted.

7. With this application, a person agrees to the state’s

overtime pay policy, which allows giving compensatory

time instead of cash payments under certain conditions.

8. An original signature and date are required for each

application.

.............................................................................................................................................................................................................

County Number Codes

01 Adair

02 Alfalfa

03 Atoka

04 Beaver

05 Beckham

06 Blaine

07 Bryan

08 Caddo

09 Canadian

10 Carter

11 Cherokee

12 Choctaw

13 Cimarron

14 Cleveland

15 Coal

16 Comanche

17 Cotton

18 Craig

19 Creek

20 Custer

21 Delaware

22 Dewey

23 Ellis

24 Garfield

25 Garvin

26 Grady

27 Grant

28 Greer

29 Harmon

30 Harper

31 Haskell

32 Hughes

33 Jackson

34 Jefferson

35 Johnston

36 Kay

37 Kingfisher

38 Kiowa

39 Latimer

40 LeFlore

41 Lincoln

42 Logan

43 Love

44 McClain

45 McCurtain

46 McIntosh

47 Major

48 Marshall

49 Mayes

50 Murray

51 Muskogee

52 Noble

53 Nowata

54 Okfuskee

55 Oklahoma

56 Okmulgee

57 Osage

58 Ottawa

59 Pawnee

60 Payne

61 Pittsburg

62 Pontotoc

63 Pottawatomie

64 Pushmataha

65 Roger Mills

66 Rogers

67 Seminole

68 Sequoyah

69 Stephens

70 Texas

71 Tillman

72 Tulsa

73 Wagoner

74 Washington

75 Washita

76 Woods

77 Woodward

Career Technology Centers

Contact the Career Technology Center nearest your home for information on test dates.

Ada Pontotoc Technology Center, 601 West 33rd Street 580-310-2271

Afton Northeast Technology Center, 19901 South Highway 69 918-257-8324

Alva Northwest Technology Center, 1801 South 11th 580-327-0344

Ardmore Southern Oklahoma Technology Center, 2610 Sam Noble Parkway 580-223-2070

Bartlesville Tri-County Technology Center, 6101 SE Nowata Road 918-331-3226

Burns Flat Western Technology Center, 621 Sooner Drive 580-562-3181

Durant Kiamichi Technology Center, 810 Waldron Road 580-924-7081

Enid Enid Community Learning Center, 2615 East Randolph 580-242-6600, ext. 123

Fort Cobb Caddo-Kiowa Technology Center, North Vo-Tech Rd. & 7th Street 405-643-5511

Guymon High Plains Technology Center, 712 Academy 580-338-0674

Idabel Kiamichi Technology Center, RR. 3, Box 177 Highway 70 580-286-7555

Lawton Great Plains Technology Center, 4500 West Lee Boulevard 580-351-6790

McAlester Kiamichi Technology Center, 301 Kiamichi Drive 918-426-0940

Okmulgee Green Country Technology Center, 1100 North Loop 56 918-756-1334

Poteau Kiamichi Technology Center, 1509 South McKenna 918-647-4525

Pryor Northeast Technology Center, 6 miles west on Highway 20 918-825-5555

Sapulpa

Tulsa

Central Tech, 1720 South Main

Downtown Tulsa Career Center, 2 North Elgin

918-224-9300

918-596-2147

Wayne Mid-America Technology Center, I-35 & Interchange 59 405-449-3391

Wetumka Wes Watkins Technology Center, 7892 Highway 9 405-452-5500

Woodward High Plains Tech, 3921 34th Street 580-571-6145

Page 3 of 4

Name:__________________________ Social Security Number:___________________________

EDUCATIONAL BACKGROUND

Are you a high school graduate or have you passed a general education development (GED) test? Yes_____ No_____

(Will only be used as required by statute, law or bonafide job requirement)

Are you fluent in any language other than English? List all

List colleges, universities or professional schools attended. If more space is needed, attach additional copies of this

page. (Transcripts may be required)

School Name

Location

From

Month/Year

Major/Minor or

Course of Study

Hours

Completed

Degree

Date

Completed

List any other job-related training or coursework: (vocational, trade, governmental, business, Armed Forces, etc.)

School Name

Location

From

Month/Year

Course of Study

Hours

Completed

Date

Completed

List job-related licensure, registration or certification (teacher certification, nursing licensure, trade licensure, etc.)

License, Registration

or Certification

Number

Date Received

Expiration Date

Licensing Agency

or Board

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Title 21 O.S. Section 358: “It shall be unlawful for any person applying for employment with the St ate of Oklahoma to make a materially

false, fictitious or fraudulent statement or representation on an employment application, knowing such statement or representation to be

materially false, fictitious or fraudulent. A violation of this subsection shall be punished as provided in subsection B of the Section 359

of this title.”

STATEMENT OF CERTIFICATION By signing this application I certify that the facts contained in this application packet are true and

complete to the best of my knowledge. I understand that if I become employed, falsified statements on this application may be grounds

for dismissal and/or removal from consideration for eligibility for other state employment or employment examinations. I authorize

investigation of all statements and information contained herein. Specifically, I authorize the State of Oklahoma to make all necessary

and appropriate investigations allowable by law to verify the information provided. I understand that if I am hired I will be required to

produce proof that I have a legal right to work in the U.S.A. in accordance with the Immigration Reform and Control Act of 1986.

________________________________________________________________________________________________

Sign Your Name Here Date

Page 4 of 4

Name:__________________________ Social Security Number:___________________________

EMPLOYMENT HISTORY

Describe your work experience in detail, beginning with your current or most recent job. Include military service (indicate

rank) and volunteer work. List each promotion or transfer as a separate job, even if they were with the same employer. If

needed, attach additional copies of this page. All information in this section must be completed. Resumes cannot be

used as a substitute for the completed application. Employers and supervisors may be contacted regarding your

work experience.

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Employer’s Name and Address _______________________________________________________________________

Exact Title of Your Position___________________________________________________________________________

From (Month/Year) _______________ To (Month/Year) _____________ Average Hours Per Week ____________

Duties (Be specific - attach extra signed and dated sheets, if necessary): ______________________________________

________________________________________________________________________________________________

Approximate Ending Salary ___________ Supervisor’s Name and Title____________________________________

Number and Occupation of Employees you Supervised ____________________________________________________

Reason for Leaving ________________________________________________________________________________