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

Type of Diploma

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 ______________________