Fillable Printable Kansas Employment Application
Fillable Printable Kansas Employment Application
Kansas Employment Application
ACCOMMODATIONS: The Americans with Disabilities Act of 1990 ensures you the right to
employment with the State of Kansas. Arrangements will be made if you have a disability that requires an
accommodation for completing an application form, interviewing or any other part of the employment process.
It is your responsibility to make your needs known to the Division of Personnel Services 785/296-4278 or the
agency to which you are applying.
Employment
Application
KANSAS...a state of excellence
THE STATE OF KANSAS IS AN EQUAL OPPORTUNITY EMPLOYER
Page 1
POSITION FOR WHICH YOU ARE APPLYING
VACANCY JOB STATE
REQUISITION # TITLE AGENCY
Return this application form to the agency which has the vacancy for which you are applying; do not return this form to any other location.
PLEASE WRITE CLEARLY, OR TYPE, AND ANSWER ALL QUESTIONS
You will have an applicant identification number only if you have registered using the Personal Data form.
If you are or have been a state employee, the applicant identification number is your employee identification number.
Applicant Identification No. Social Security No.
(Optional)
Name
Last First Middle
Address
Street, Apt. # City State Zip Code
Telephone ( ) (Day) Message Number ( )
Email Address
Are you known to employers/references/schools by another name? If yes, name No
Have you worked for the State of Kansas before or do you now? If yes, dates No
How did you hear about us?
______________________________
Are you claiming veterans’ preference? Yes □ No □ If you are claiming veterans' preference for the first time please mail a copy of your
DD214 - copy of discharge or documentation in form of a letter from the United States Department of Veterans Affairs to verify service-connected disability, copy of
a marriage license to verify relationship as a spouse to a service member, a letter or notice from the Federal Government showing that their spouse died while serving
in the armed forces, or other relevant documentation that would help qualify an individual for veterans’ preference in accordance with the eligibility criteria set forth
in K.S.A. 73-201. Please mail discharge or documentation to the Kansas Dept. of Administration, Division of Personnel Serv., 900 S.W. Jackson, Rm 252S, Topeka,
Kansas 66612 or Fax to (785) 291-3715.
Have you ever been convicted of a felony? Yes □ No □
INFORMATION REGARDING CONVICTION RECORD WILL
NOT NECESSARILY BAR AN APPLICANT FROM EMPLOYMENT; INDIVIDUAL CIRCUMSTANCES WILL BE CONSIDERED
RELATIVE TO THE JOB SOUGHT.
Educational Background
Institution and City, State Degree or
Certificate Attained
Major Area of
Study
Credit Hours or Academic
Years Completed
High School/GED
High School/GED transcript not required.
College or University
Graduate School
Vocational, Technical,
Business School
Other Education
Vocational Licenses/Registrations (Attach copy of documents)
Type
License/Registration
Number
Issuing Authority Issue Date
Expiration Date
Page 2
Work Experience - List your last three employers or last three positions, starting with the most
recent. Attach a Supplement to Employment Application or other pages if you want to include more positions.
Month & Year
From:
To:
Name/Address of Employer Reason for Leaving
□ Paid Employment
□ Unpaid Experience
□ Full-time □ Part-time
□ Number of hours per wk: _____
Ending Pay $_________ per_____
Title: Duties:
List Computer Skills used in this Position
_____________________________________________________________________________________
__________________________________________________________________________________________________________________
Largest Number of People Supervised ______ Supervisor’s Name ___________________________________ Supervisor’s Phone Number
____________________
Month & Year
From:
To:
Name/Address of Employer Reason for Leaving
□ Paid Employment
□ Unpaid Experience
□ Full-time □ Part-time
□ Number of hours per wk: _____
Ending Pay $ ________ per_____
Title: Duties:
List Computer Skills used in this Position
_____________________________________________________________________________________
__________________________________________________________________________________________________________________
Largest Number of People Supervised ______ Supervisor’s Name ___________________________________ Supervisor’s Phone Number
Month & Year
From:
To:
Name/Address of Employer Reason for Leaving
□ Paid Employment
□ Unpaid Experience
□ Full-time □ Part-time
□ Number of hours per wk: _____
Ending Pay $ ________ per_____
Title: Duties:
List Computer Skills used in this Position
_____________________________________________________________________________________
__________________________________________________________________________________________________________________
Largest Number of People Supervised ______ Supervisor’s Name ___________________________________ Supervisor’s Phone Number
Page 3
Other Employment: (Account for all employment in at least the last 10 years)
Name and Address of Company Position Held
Employment Dates
Other Related Experiences: Please describe here any other related professional certifications, honors, special skills, qualifications, or
experiences not mentioned elsewhere, i.e., equipment or machines operated, etc.
Computer Skills (name software and hardware) __ ___________________________________________________________________________
___________________________________________________________________________________________________________________
SUPPLEMENTAL WORK EXPERIENCE _______________________________________________________________________________
___________________________________________________________________________________________________________________
_
____________________________________________________________________________________________________________
References Include supervisors and persons w e may contact to verify your performance and qualifications.
Name
Your supervisor? Yes No
Occupation
Organization
Mailing Address
Phone (Day)
Name
Your supervisor? Yes No
Occupation
Organization
Mailing Address
Phone (Day)
Name
Your supervisor? Yes No
Occupation
Organization
Mailing Address
Phone (Day)
AFFIRMATION
I affirm that the facts set forth above in my application for employment are true, correct and complete to the best of my knowledge. I understand
that I may be required to submit information not requested on this application form; that the employing agency may verify any information
provided by me in the employment process; and that incomplete information or omission of my signature is just cause for rejection of my
application.
I understand and agree that, if hired, my employment would be contingent upon conditions specific to the position for which I am applying. I also
understand that any omission of information, or erroneous information provided in any part of the employment process, would be sufficient
cause for discharge. I agree that the employing agency may, at its sole discretion, provide compensatory time off in lieu of overtime pay if I were
employed in a nonexempt position and if there were no existing agreement to the contrary.
SIGNATURE OF APPLICANT DATE
If you are applying for a vacancy which has a requisition number (Req No), you must also register using the Personal Data form, if you have not already done so.
Personal Data forms are available from any state agency or Workforce Center. Return this application form to the agency which has the vacancy for which you are
applying; do not return this form to any other location. For general information about the State of Kansas employment process, phone Civil Service Employment
Information (Department of Administration, Topeka, Kansas) at 785-296-4278.
THE STATE OF KANSAS IS AN EQUAL OPPORTUNITY EMPLOY ER
Promoting Diversity in a Diverse State
DA 215 – Rev. 8/11
