Fillable Printable Application for Employment - State of New Jersey
Fillable Printable Application for Employment - State of New Jersey
Application for Employment - State of New Jersey
State of New Jersey
NAME (Last, First, MI)
POSITION TITLE DEPARTMENT
“People at work for better government through
competence, caring, and commitment.”
Job applicants are considered for all positions without regard to race, creed, color,
national origin, sex, affectional or sexual orientation, age, religion, marital, or veterans
status, or disability. The State will not tolerate any form of discrimination or sexual
harassment.
The Americans with Disabilities Act of 1990 prohibits employers from discriminating
against any qualified person on the basis of a disability. The State of New Jersey makes
reasonable accommodations during all aspects of the employment process, such as testing
and interviews. The State also makes reasonable accommodations in the work
environment to enable a person with a disability to perform the essential job functions
and to participate equally with co-workers without disabilities. However, the State can
only make reasonable accommodations when it is aware of a disability. It is up to you
to inform the prospective employer if you need a reasonable accommodation. The
employer may ask you for documentation to support your request for a reasonable
accommodation. If you need a reasonable accommodation before the interview process
begins, please inform the agency personnel office for which you are applying.
The State of New Jersey is an Equal Opportunity Employer.
DIVISION
APPLICANT - DO NOT COMPLETE THIS SECTION
Please PRINT or TYPE answers. Feel free to add any information which will help to place you. Please be aware that
misrepresentation may be cause for removal.
1. NAME (Last, First, MI) 2. Home Phone # (Area Code) 3. Work Phone # (Area Code)
4a. ADDRESS 4b. If entry is 4a is your mailing address only, enter name of street,
townshi
p
, cit
y
, or borou
g
h in which
y
ou live.
Number, Street,
Apt. #, Etc. Î
CityÎ
StateÎ ZipÎ
5. Position applying for (or type of work you are interested in)
z Proof of Age, Education, Military Status, and Citizenship may be required upon employment offer
6. In what state regions are you willing to work? “X” all that apply: NORTHERN CENTRAL SOUTHERN
7. Indicate preferred work schedule:
Full-Time Part-Time Temporary Days Evenings Late Nights Any Shift Rotating Shift
8. Are you 18 years old or older? (If under 18, you will be required to submit working papers if offered employment.) Yes No
9a. Do you possess a driver’s license that is valid in New Jersey? Yes No 9b. Do you possess a Commercial Driver License? Yes No
(Answer these questions only if it is a requirement as indicted on the job announcement or job specification.)
10. Are you either a U.S. citizen or an alien authorized to work in the U.S.? Yes No
11. Have you ever been convicted of a crime which has not been expunged by the Court? Yes (If yes, give details in Block Number 16) ) No
(A conviction will not necessarily preclude you from employment.)
12. Are you a Veteran? Yes No
*If yes, have you established Veteran’s Preference with the New Jersey Department of Personnel after April 1, 1980? Yes No
13. Are you now or have you ever been a member of any Public Employee’s Retirement System? Yes* No
(If yes, indicate system name and membership number in Block Number 16.)
14. Have you ever worked or been employed under a different name? Yes (If yes, specify here: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . ) No
15. Are you currently on a special or regular reemployment list, or any list resulting from an examination administered by the New Jersey Department
of Personnel?
Yes* No * (If yes, indicate Titles and Symbols here:)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16. EXPLANATIONS (Use this block for explanations to questions. Attach additional sheets if necessary.)
17. EDUCATION/SKILL HISTORY: Please list all vocational, technical, correspondence schools, colleges and universities you have attended. Upon
employment be prepared to provide supporting documentation of schools attended. Attach additional sheets if necessary.
z Circle the number indicating the highest grade of school you have completed:
1 2 3 4 5 6 7 8 HIGH SCHOOLÎ 9 10 11 12 GED COLLEGEÎ 1 2 3 4 GRADUATEÎ 1 2 3 4 5 6
Name and Address of School
Did you
Graduate?
Credit Hrs.
Earned
Major Subject
# of Credits
in Ma
j
or
Degree
Received
HIGH SCHOOL (last attended)
YES
NO
COLLEGE or UNIVERSITY
YES
NO
GRADUATE SCHOOL
YES
NO
OTHER FORMAL TRAINING (include Military)
YES
NO
Page 2
18. F
O
REIGN L
A
N
G
UAGE ABILITIES (Answer is
Optional)
If there are any foreign languages, including sign languages, in which you are proficient enough to communicate on a job, and are willing to use on the
job (now or in the future), please list them here.
19. CLERICAL SKILLS
(a) TYPING
YES NO WPM: _ _ _ _ _ _
(b) STENOGRAPHY
YES NO WPM: _ _ _ _ _ _
Office machines operated, computer systems/software used, and/or special
skills
20. List all employment starting with present or last position and work back, including military experience.
PLEASE PRINT OR TYPE. USE ADDITIONAL SHEETS IF NECESSARY.
From
Mo.:_ _ _ _ _
Yr.: _ _ _ _ _
To
Mo.:_ _ _ _ _
Yr.: _ _ _ _ _
POSITION TITLE
zGive number of staff su
p
ervised
,
if an
y
:
_
_
_
_
_
_
SUPERVISOR’S NAME
zTele
p
hone Number:
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
Salary or Wage
Starting: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Ending: _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _
FULL TIME PART TIME (List number of hrs. per week: _ _ _ _ _ _)
EMPLOYER’S NAME AND COMPLETE ADDRESS
REASON FOR LEAVING
DESCRIPTION OF DUTIES
From
Mo.:_ _ _ _ _
Yr.: _ _ _ _ _
To
Mo.:_ _ _ _ _
Yr.: _ _ _ _ _
POSITION TITLE
zGive number of staff su
p
ervised
,
if an
y
:
_
_
_
_
_
_
SUPERVISOR’S NAME
zTele
p
hone Number:
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
Salary or Wage
Starting: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Ending: _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _
FULL TIME PART TIME (List number of hrs. per week: _ _ _ _ _ _)
EMPLOYER’S NAME AND COMPLETE ADDRESS
REASON FOR LEAVING
DESCRIPTION OF DUTIES
From
Mo.:_ _ _ _ _
Yr.: _ _ _ _ _
To
Mo.:_ _ _ _ _
Yr.: _ _ _ _ _
POSITION TITLE
zGive number of staff su
p
ervised
,
if an
y
:
_
_
_
_
_
_
SUPERVISOR’S NAME
zTele
p
hone Number:
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
Salary or Wage
Starting: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Ending: _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _
FULL TIME PART TIME (List number of hrs. per week: _ _ _ _ _ _)
EMPLOYER’S NAME AND COMPLETE ADDRESS
REASON FOR LEAVING
DESCRIPTION OF DUTIES
May we contact all employers/supervisors listed? YES NO (Indicate exceptions):
21. Use this space to describe any internships, licenses, certifications or registrations related to the position for which you are applying. Give
name of State in which license, certification or registration is held or dates and location of internship. If specific license or certification is required
for your position, you will be required to present the appropriate credential(s) prior to employment, and you will be responsible to renew the
credential(s) and advise the personnel office if the credential(s) expires or is revoked.
Page 3
GENERAL INFORMATION (Please print or type. Use additional sheets if necessary.)
22. Are you engaged in any business activity or employment which you plan to continue if employed by the State? If yes, your outside employment
will be subject to further review regarding conflicts of interest.
NO YES If yes, explain:
23. Please add any additional information which will help in placing you where you are best qualified. Include such items as: honors, hobbies,
publications, volunteer work, public speaking and writing experience, membership in professional or scientific societies.
24. List three people unrelated to you whom we may contact for information concerning your qualifications.
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Occupation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Occupation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Phone #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Occupation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
z Please indicate a telephone number where and at what time you may be contacted for an interview:
I understand that if I plan to engage in other business or employment while working for the State in any of its Departments or Agencies,
prior approval will be necessary before accepting employment since there may be restrictions in accordance with the New Jersey
Conflicts of Interest Law and/or the State, Department or Agency Code of Ethics.
I authorize my former employers to release any information they may have concerning my employment records and I release the State of
New Jersey and all previous employers listed above from all liability whatsoever that may issue from securing this information. I further
authorize representatives of this agency to verify any and all information contained in this application, including education, and to review
any and all criminal history, military and disciplinary records of any source.
I CERTIFY that the information on this application is complete and accurate, to the best of my knowledge. I understand that any
misleading or incorrect information may render this application void and be just cause for immediate termination if employed.
STOP:
Please Return Completed Application
to the Human Resources Office.
Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ _ _ _
THIS SECTION FOR PERSONNEL OFFICE USE ONLY
Page 4
STATE OF NEW JERSEY
AFFIRMATIVE ACTION INFORMATION FORM
The State of New Jersey is an Equal Opportunity Employer
DPF-663 AAIF Revised 04-28-10
To Be Completed By Applicant
Not For Interview Purposes
To Be Filed Separately With
Affirmative Action Officer
GENDER:
Male Female
The State of New Jersey seeks to increase the richness and diversity of its workforce and in doing so become the employer of
choice for all people seeking to work in State government. In order to judge the effectiveness of our efforts to attract and
employ a diverse workforce, as well as comply with Federal and State reporting requirements, we ask that you take the time
to answer a few brief questions.
This form is
not part of your application for employment and will not be considered in any hiring decision. Any information
submitted on this form will be considered confidential and will be filed separately by the agency’s affirmative action officer.
The State of New Jersey is an equal opportunity employer. The New Jersey State Policy Prohibiting Discrimination in the
Workplace provides that applicants for employment are considered without regard to race, creed, color, national origin,
nationality, ancestry, sex/gender, affectional or sexual orientation, gender identity or expression, age, marital status, civil
union status, domestic partnership status, familial status, religion, atypical heredity cellular or blood trait, genetic information,
liability for service in the Armed Forces of the United States or disability.
A. Ethnicity: (Please Select One)
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South
or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic or Latino
B. Race: (Please Select one)
Black or African American: A person having origins in any
of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander: A person having
origins in any of the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islands.
White: A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
The EEOC has recently updated its data collection requirements to allow employees who may be of two or more races to identify themselves.
If you are of more than one race please identify them below.
C. Two or More Races: (If applicable, select the two or more races with which you identify)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
If you require an accommodation for the interview process please advise the HR representative at the department where
you are applying for the job.
American Indian or Alaska Native: A person having origins in any of
the original peoples of North and South America (including Central
America), who maintains tribal affiliation or community attachment.
Asian: A person having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand and Vietnam.
DATE:
POSITION(S) APPLIED FOR:
DIVISION:
APPLICANT NAME: (Last, First, M) APPLICANT ADDRESS:
REFERRAL SOURCE:
How did you learn of this position?
