Fillable Printable CS-14 application - Rhode Island Judiciary
Fillable Printable CS-14 application - Rhode Island Judiciary
CS-14 application - Rhode Island Judiciary
DIVISION OF HUMAN RESOURCES APPLICATION FOR EMPLOYMENT
Office of Personnel Administration An Equal Opportunity Employer CS-14 Rev. 12/17/13
THIS SECTION IS TO BE FILLED IN BY APPOINTING AGENCY
Class Title and Number
Identify below the license or certificate required by the class specification and held by the applicant
Type of License _____________________________________ License Number _______________ Date Issued __________
PRE-EMPLOYMENT INFORMATION – TO BE FILLED OUT BY APPLICANT
Applicants selected for an interview will be required to complete the Criminal Record Supplemental Form (CS-14B) at the
time of initial interview or anytime thereafter. A conviction is not necessarily a bar to employment. See RIGL §28-5-7(7).
1. Print Name (as you wish it to appear on payroll check and official records)
___________________________________________________________________________________
2. Telephone Number
___________________________________________
3. Print Actual Address (Street and Number, City, State and Zip Code)
___________________________________________________________________________________
4. Mailing Address (if different)
_____________________________________
EDUCATION
ELEMENTARY AND SECONDARY EDUCATION
Highest school grade completed
1 2 3 4 5 6 7 8 9 10 11 12
Type of High School Course
__________________________________________________________
Name and address of elementary or secondary school last attended
_________________________________________________________________________________
Did you graduate?
YES NO
COLLEGE, BUSINESS SCHOOL, TRADE SCHOOL AND OTHER EDUCATION
Dates Attended
Name of School
Major and/or Course of Study
From
To
Type of Diploma
or
Degree Earned
If No Degree,
# of Credits
5. Have you ever worked for the State before?
NO YES - Name of agency/organization:
______________________________________
6. Have you ever been dismissed from any position? If your answer is yes, give
details on an attached sheet.
YES NO
EXPERIENCE
7. Describe below all the positions you have held in the past ten years. In addition, describe any other experience which you think may qualify you for
this job. Include all previous employment with the State of Rhode Island. Begin with your present or most recent employment.
Name of Employer
Type of Business
Lowest Weekly Salary
From (Date)
Address of Employer
Title of Position
Highest Weekly Salary
To (Date)
Duties:
Name of Employer
Type of Business
Lowest Weekly Salary
From (Date)
Address of Employer
Title of Position
Highest Weekly Salary
To (Date)
Duties:
Name of Employer
Type of Business
Lowest Weekly Salary
From (Date)
Address of Employer
Title of Position
Highest Weekly Salary
To (Date)
Duties:
Name of Employer
Type of Business
Lowest Weekly Salary
From (Date)
Address of Employer
Title of Position
Highest Weekly Salary
To (Date)
Duties:
THIS AFFIRMATION MUST BE COMPLETED
I certify that there are no willful misrepresentations and falsifications of the above statements and answers to questions. I understand that should an
investigation disclose such misrepresentations and falsifications, my application may be rejected and, should I be employed, my service may be
terminated.
_____________________ ________________________________________
DATE SIGNATURE
STOP! Do not write in the spaces below!
IF CANDIDATE IS HIRED, ALL POST-EMPLOYMENT INFORMATION BELOW MUST BE COMPLETED.
YOU MUST ALSO ATTACH THE “CRIMINAL RECORD SUPPLEMENTAL QUESTIONNAIRE (CS14-B) TO THIS APPLICATION.
Approved by Appointing Authority/Signature ______________________________________________ DATE _______________________
Title of Appointing Authority ______________________________________________
8. Date of Birth
____________
9. Your Social Security No.
_____________________
10. Age
______
11. Sex Male
Female
12. Marital Status Married Single
Divorced Widowed Separated
13. Spouse’s Name
__________________________
14. Spouse’s Date of Birth
____________
15. Spouses Social Security No.
___________________________
16. YOUR Maiden Name
(if
applicable)
___________________________
17. Are you a Veteran?
(Including Desert Storm activation)
Yes No
19. Are you a disabled Veteran? (RIGL-36-4-19)
Yes No
18. Are you a war Veteran? Yes No
If yes, identify below the War/Conflict and the dates of
service that apply:
____________________________________________
War/Conflict Service Dates
20. Do you have the proper “WORK
AUTHORIZATION” documentation to
work in the U.S.?
Yes No
SIGNATURE ________________________________________________________ DATE ______________________
