Fillable Printable Application for Employment - Iowa

Application for Employment - Iowa

CFN 552

0072 R 1/07

Section 1 General Instructions

n This application will allow you to apply for specific jobs in Iowa State Government.

n You must include the following information: Social Security number or an assigned alternate nine-digit number, job

title, job vacancy number, and your name, mailing address, education and employment history. You must also sign

the application on page 6. Call (515) 281-5239 if you wish to be assigned an alternate nine-digit number.

n An accurate Job Requisition Number is required to process your application to be considered for a position or positions.

n Each vacancy listed in our job announcements includes specific application instructions, job vacancy numbers and application

deadline dates. Please follow those application instructions closely.

n If you provide incomplete or inaccurate information, we may be unable to process your application.

n You must ensure that this application is received on or before the announced deadline date, at the announced location. We are

not responsible for late, lost, misdirected or damaged mail.

n All mail will be sent to you at the address you provide on this form.

n For jobs requiring an exam at one of our examination centers, you will be notified by mail. See Section 2 for typing tests.

n You may make clear photocopies of this form to submit as your official application. You will be charged for photocopying done

by the Department of Administrative Services – Human Resources Enterprise (DAS-HRE).

n Students applying for Internships must complete this application and an Internship Supplement form.

n Please use a blue or black ink pen when completing this application. Handwriting must be legible.

Applying For a State Job

n A list of current vacancies is available on DAS-HRE’s Website: das.hre.iowa.gov, at all Iowa Workforce Development Centers,

state agency offices, and public libraries.

n A limited number of job titles are open to continuous application. These titles are available on our website, or by calling or

visiting an Iowa Workforce Development Center.

n Return your completed application by mailing it or delivering it to the address listed above, or by faxing it to (515) 281-7970.

IF FAXED, KEEP THE ORIGINAL.

n This application will remain valid for two years. You may request to add vacancies, job titles, update information or change

availability choices by writing to the address or e-mail listed above or by calling (515) 281-3087 (automated call processing

system).

n All individuals hired must provide proof of their identity and eligibility to work in the United States at the time of hire.

n Applicants with a disability may request testing accommodations by calling (515) 281-3087 or by writing to the address or

e-mail listed above. Hearing impaired applicants may contact us through Relay Iowa by calling 1-800-735-2943.

How to Receive the Most Responsive Service for Questions Concerning the State’s Hiring Process

Job vacancy information and application services for specific state jobs are available for your use seven days a week, 24 hours a

day on our website at das.hre.iowa.gov, so you can access our services at your convenience.

You may also use our call processing system at any time to access our services by calling (515) 281-3087. When calling with

multiple requests, select one of the access numbers and leave your entire message there. Do not leave your message

in more than one mailbox. You may also send us an e-mail at: [email protected] to request information regarding the

State’s hiring process.

Iowa Department of Administrative Services –

Human Resources Enterprise

Hoover State Office Building, Level A

1305 East Walnut

Des Moines, IA 50319-0150

Phone: (515) 281-3087 Fax: (515) 281-7970

Website: das.hre.iowa.gov/

E-mail: [email protected]

Application

For State

Employment

CFN 552

0072 R 1/07

Section 2 Applicant Data

Print or Type

*First Name M.I. *Last Name

*Address line 1 Address line 2

*City *State *Zip

( ) ( )

*Phone (area code) Home phone Phone (area code) Work phone Other phone (i.e., mobile)

Contact e-mail address Fax Web address

Fields with * are required

JOB TITLES (see instructions on page 1) Job Vacancy Number*

*An accurate job vacancy number is required to process your application.

Preferred Method of Contact: E-mail U.S. Postal Service

Are you a permanent State of Iowa employee? Yes No

If Yes, please check one:

Executive Branch Regents Community Based Corrections Judicial Branch Legislative Branch

What Executive Branch Department do you work for?

Education

Circle highest year of education completed

1 2 3 4 5 6 7 8 9 10 11 12 High School graduate or equivalent (GED)? ¨ Yes ¨ No

Dates Attended Credit Received Field of Study or Area of Concentration

Name and Location of Schools

Attended Beyond High School

Mo/Yr Mo/Yr

Quarter

Hours

Semester

Hours

Major Hours Minor Hours

Degree/

Certification

If you are working toward a degree, please give the anticipated completion date: Do not send a transcript unless requested.

GUIDELINES FOR ACCEPTING TYPING TEST SCORES ARE AS FOLLOW:

We accept typing scores from the following sources: Iowa Workforce Development Offices, high schools, temporary employment

offices (e.g., Olsten or Kelly), private companies or area community colleges. The criteria for accepting scores from these sources are:

1) Typing scores must be submitted on official letterhead of the company or school.

2) Scores must be signed and dated within the last six months by a teacher, test administrator or human resource official.

3) Information required.

a) Gross number of words typed in a five minute timed test.

b) Number of errors.

c) Net words per minute (one point deduction for each error).

4) Applicant name and social security number.

Most Workforce Centers are willing to fax the results upon request. Our fax number is (515) 281-7970.

CFN 552

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Social Security or Alternate Number

Section 3 Experience

n List your work experience starting with the most recent. If you have held more than one job with the same organization, list

each separately.

n Provide complete descriptions of job duties, including the exact dates of employment and the average number of

hours worked per week.

n Describe your experience in detail. Include the number and titles of people supervised and equipment or facilities managed.

n Describe duties that are relevant to the position/s for which you are applying, including any selectives.

n Describe volunteer and homemaker experience, if applicable.

n Resumes submitted with the application must show dates of employment (month/year) and hours worked per week.

Your name and social security number or assigned alternate nine-digit number must be shown at the top of each

resume page and accompanying documents.

Organization (most recent):

Address:

City State Zip Code

Your Title:

Supervisor’s Title:

From

Month Day Year

Average number of hours

worked per week:

Duties:

Organization:

Address:

City State Zip Code

Your Title:

Supervisor’s Title:

From

Month Day Year

Average number of hours

worked per week:

Duties:

Organization:

Address:

City State Zip Code

Your Title:

Supervisor’s Title:

From

Month Day Year

Average number of hours

worked per week:

Duties:

You may describe additional work experience or add more detail to the “Duties” section on a separate sheet of

paper. Use the same format as used here. Be sure to include your name and social security number or alternate

nine-digit number at the top of each extra page.

CFN 552

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Section 4 Availability

Check All Boxes That Apply

Your availability choices are used to refer your name to state departments for employment consideration for job classes open to

continuous application and internship only.

¨ Full-Time 40 hours per week

¨ Part-Time less than 40 hours per week

¨ Travel varies with each job

¨ Day Shift varies, usually 8 a.m. to 4:30 p.m.

¨ Eve Shift varies, usually 4 p.m. to 12 midnight

¨ Night Shift varies, usually 12 midnight to 8 a.m.

¨ Any Shift will work anytime

¨ Weekends will work Saturdays and/or Sundays

County 29 (Des Moines County) Does Not Include the City of Des Moines. County 77 (Polk County) Includes All of Polk County.

Polk (Capitol Complex) is Limited Only to the Capitol Complex Area.

Mark Only Counties In Which You Will Work (See Map): ¨ Mark Here for All Counties

¨ 1 Adair

¨ 2 Adams

¨ 3 Allamakee

¨ 4 Appanoose

¨ 5 Audubon

¨ 6 Benton

¨ 7 Black Hawk

¨ 8 Boone

¨ 9 Bremer

¨ 10 Buchanan

¨ 11 Buena Vista

¨ 12 Butler

¨ 13 Calhoun

¨ 14 Carroll

¨ 15 Cass

¨ 16 Cedar

¨ 17 Cerro Gordo

¨ 18 Cherokee

¨ 19 Chickasaw

¨ 20 Clarke

¨ 21 Clay

¨ 22 Clayton

¨ 23 Clinton

¨ 24 Crawford

¨ 25 Dallas

¨ 26 Davis

¨ 27 Decatur

¨ 28 Delaware

¨ 29 Des Moines County

¨ 30 Dickinson

¨ 31 Dubuque

¨ 32 Emmet

¨ 33 Fayette

¨ 34 Floyd

¨ 35 Franklin

¨ 36 Fremont

¨ 37 Greene

¨ 38 Grundy

¨ 39 Guthrie

¨ 40 Hamilton

¨ 41 Hancock

¨ 42 Hardin

¨ 43 Harrison

¨ 44 Henry

¨ 45 Howard

¨ 46 Humboldt

¨ 47 Ida

¨ 48 Iowa

¨ 49 Jackson

¨ 50 Jasper

¨ 51 Jefferson

¨ 52 Johnson

¨ 53 Jones

¨ 54 Keokuk

¨ 55 Kossuth

¨ 56 Lee

¨ 57 Linn

¨ 58 Louisa

¨ 59 Lucas

¨ 60 Lyon

¨ 61 Madison

¨ 62 Mahaska

¨ 63 Marion

¨ 64 Marshall

¨ 65 Mills

¨ 66 Mitchell

¨ 67 Monona

¨ 68 Monroe

¨ 69 Montgomery

¨ 70 Muscatine

¨ 71 O’Brien

¨ 72 Osceola

¨ 73 Page

¨ 74 Palo Alto

¨ 75 Plymouth

¨ 76 Pocahontas

¨ 77 Polk

¨ 77 Polk (Capitol Complex Only)

¨ 78 Pottawattamie

¨ 79 Poweshiek

¨ 80 Ringgold

¨ 81 Sac

¨ 82 Scott

¨ 83 Shelby

¨ 84 Sioux

¨ 85 Story

¨ 86 Tama

¨ 87 Taylor

¨ 88 Union

¨ 89 Van Buren

¨ 90 Wapello

¨ 91 Warren

¨ 92 Washington

¨ 93 Wayne

¨ 94 Webster

¨ 95 Winnebago

¨ 96 Winneshiek

¨ 97 Woodbury

¨ 98 Worth

¨ 99 Wright

Lyon

Sioux

Scott

O’Brien

Clay

Buena Vista

Plymouth

Cherokee

Muscatine

Ida

Woodbury

Crawford

Carroll

Monona

Fremont

Pottawattamie

Shelby

Harrison

Mills

Page

Taylor

Montgomery

Polk

Adams

Decatur

Union

Ringgold

Dallas

Guthrie

Audubon

Madison

Adair

Warren

Cass

Clarke

Lucas

Wayne

Jasper

Marion

Louisa

Des Moines

Davis

Van Buren

Jefferson

Appanoose

Lee

Wapello

Henry

Monroe

Washington

Poweshiek

Mahaska

Iowa

Johnson

Keokuk

Osceola

Dickinson

Emmet

Kossuth

Palo Alto

Pocahontas

Calhoun

Sac

Winnebago

Webster

Humboldt

Greene

Boone

Hancock

Wright

Hamilton

Story

Worth

Cerro Gordo

Franklin

Hardin

Marshall

Tama

Benton

Linn

Jones

Cedar

Jackson

Clinton

Dubuque

Delaware

Buchanan

Black Hawk

Grundy

Butler

Floyd

Mitchell

Howard

Chickasaw

Bremer

Winneshiek

Fayette

Allamakee

Clayton

Ames

Council

Bluffs

Waterloo

Cedar

Rapids

Iowa City

Davenport

Burlington

Ottumwa

Marshalltown

Glenwood

Clarinda

Creston

Mt. Pleasant

Ft. Madison

Oakdale

Anamosa

Independence

Toledo

Eldora

Woodward

Rockwell

City

Cherokee

Newton

Mitchellville

Sioux

City

Fort

Dodge

Mason

City

Des

Moines

n Your name will be referred for vacancies only in the counties you have selected.

CFN 552

0072 R 1/07

Section 5 Applicant Survey

Social Security or Alternate Number

This information is requested as a part of Iowa state government’s responsibility to maintain a nondiscriminatory workplace and to

provide equal employment opportunity for all. Your responses are deemed confidential, and this section is removed before your

application is processed. The information you provide is only used in summary reports to assist the Department with planning,

monitoring and evaluating its equal opportunity programs. Providing this information is voluntary; however, your cooperation is

critical to ensuring we have a diverse workforce. Your choice not to self-disclose will not adversely affect you as an applicant.

Please write your numbered response to questions A through F in the corresponding boxes.

A. What sex are you?

0. Male

1. Female

C. What is your highest level of education?

0. 0-8 years

1. 9-12 years, but not a high school graduate

2. High school graduate or GED

3. Post high school vocational or business school

4. Some college, less than BA or BS degree

5. BA, BS or similar undergraduate degree

6. MA, MS or similar graduate degree

7. PhD, JD or similar professional degree

8. MD or similar professional degree

E. Do you have a disability?

(An individual with a disability is any person who: (1) has a

physical or mental impairment that substantially limits one or more

major life activities; (2) has a record of such impairment; (3) is

regarded as having such an impairment.)

Examples of disabilities:

Physical or mental impairment – Any physiological disorder or

condition, cosmetic disfigurement, or anatomical loss affecting

one or more of the following body systems: neurological,

musculoskeletal, special sense organs, respiratory (including

speech organs), cardiovascular, reproductive, digestive,

genitourinary, hernic and lymphatic, skin and endocrine.

Major life activities – means functions such as caring for one’s

self, performing manual tasks, walking, seeing, hearing, speaking,

breathing, learning, working, and receiving education or vocational

training.

0. No

1. Yes

2. Do not wish to self-disclose

B. What is your age?

0. under 18

1. 18-29

2. 30-39

3. 40-49

4. 50-59

5. 60-69

6. 70 or over

D. Of which racial/ethnic group do you consider yourself a

member?

0. White: (Not Hispanic or Latino) – A person having origins in

any of the original peoples of Europe, the middle East, or

North Africa

1. Black or African American: (Not Hispanic or Latino) – A

person having origins in any of the black racial groups of

Africa

2. Asian: (Not Hispanic or Latino) – A person having origins in

any of the original peoples of the Far East, Southeast Asia,

or Indian Subcontinent

3. American Indian or Alaska Native: (Not Hispanic or Latino) –

A person having origins in any of the original peoples of North

and South America (including Central America), and who

maintain tribal affiliation or community recognition

4. Hispanic or Latino: A person of Cuban, Mexican, Puerto

Rican, Central or South American, or other Spanish culture or

origin, regardless of race

5 Native Hawaiian or Other Pacific Islander: (Not Hispanic or

Latino) – A person having origins in any of the peoples of

Hawaii, Guam, Samoa, or other Pacific Islands

6 Two or More Races: (Not Hispanic or Latino) – All persons

who identify with more than one of the above five races

F. How did you learn about this job?

0. Direct contact with DAS-HRE at its office, Job Information

Center or through its Jobline

1. Iowa Workforce Development (IWD) Center or IWD Website

2. Iowa state agency or a state employee

3. Contact with state agency other than those listed in

0, 1, 2, 8 & 9

4. Public Library

5. Internet/website other than the DAS-HRE and IWD websites

6. College, university or community college career or

placement offices

7. Newspaper, periodical or trade journal

8. Career fair attended by a state of Iowa agency

9. DAS-HRE website

CFN 552

0072 R 1/07

Section 6 Special Requirements or Qualifications

Special Requirements or Qualifications

Some jobs have special requirements. They will be found on the vacancy announcement and/or the job class description in the

section titled “Competencies Required,” or “Selective Certification.” Write needed information below.

Education

Quarter

Hours

Semester

Hours

Experience Dates

From

List all languages, including American Sign Language, Braille and Tactile Braille, in addition to English, that you speak, read and/or write fluently. For each language

listed, indicate S for Speak, R for Read, or W for Write fluently. You will be required to demonstrate your skill in all areas and languages you indicate fluency.

If you possess a license or certificate to practice a trade or profession, complete the following:

Name of Trade or Profession: License Number:

Issued by: Specialty: Expiration Date:

If a teacher’s certificate, Endorsement Numbers: Approval Numbers:

Veterans Points

Upon request, veterans points shall be applied to honorably discharged veterans as defined in Iowa Code Chapter 35C who are

residents of Iowa. Former members of the reserve forces or Iowa National Guard who served at least 20 years after January 28,

1973 are eligible. Reserve force or Iowa National Guard veterans who were activated for federal duty, other than training, for a

minimum of 90 days and were discharged under honorable conditions or retired under Title 10, United States Code are eligible.

Veterans with a service-connected disability, a Purple Heart, or who are receiving disability compensation or pension through the

U.S. Veterans Administration may also request veterans points. Proof of disability from the Veterans Administration must be

submitted and updated every two years. A copy of your certified DD214 must be submitted for proof of service.

Veterans Points: Do you want to be considered for veterans points? ¨ Yes ¨ No

If yes, you must provide proof of service by submitting a photocopy of your DD-214 form.

Read the Following Before Signing

I certify that this application (and any copy or facsimile of same) and applicant survey contains no willful misrepresentation and that

the information is true and complete to the best of my knowledge. I understand that:

n Should an investigation at any time disclose otherwise, my application may be rejected, my name may be removed from

consideration for employment, I may be discharged from employment with the State of Iowa, and I may be disqualified from

applying for any other position under the jurisdiction of the Iowa Department of Administrative Services – Human Resources

Enterprise.

n Information on this application and any documents submitted to be included with this application may, in compliance with Iowa

Code Chapter 22, become public records and may be made available to the public upon request. Only information deemed

confidential in accordance with applicable statutes may be withheld from public disclosure.

n Background investigations may be conducted as part of this application for employment. These include, but are not limited to,

inquiries relating to driving records for jobs requiring travel, inquiries about convictions where job related, and any other

investigations deemed necessary and relevant by the employer.

The State of Iowa complies with the federal law requiring preemployment, random, post-accident, reasonable suspicion, and return

to duty drug and alcohol testing for all persons in positions requiring a Commercial Drivers License.

By signing this Application for State Employment, I am consenting to any reasonable inquiry that may be necessary to

verify the information I have provided on this form or that I may otherwise provide in conjunction with my application

for state employment.

Signature: Date: