Fillable Printable State of Colorado Employment Application Form
Fillable Printable State of Colorado Employment Application Form
State of Colorado Employment Application Form
7/99Subject to revisions1
STATE OF COLORADO
EMPLOYMENT APPLICATION FORM B
SUBMIT COMPLETED FORMTO AGENCY
LISTED IN THE JOB ANNOUNCEMENT
PLEASE TYPE OR PRINT IN BLACK INK
Enter below the State Job Title, Class Code and Position Number (if one appears) as listed on the job announcement to which you are responding.
Application Form B is accepted only for an announced position. Additional instructions on following page.
State Job Title / Working Title:Class Code:Position / Announcement
Number:
Social Security Number: Please fill in the
shaded boxes to the right with your SSN
--
Name (Last, First, Middle Initial, Suffix):
Mailing Address (Street, Apt/Unit or P.O. Box):
City State Zip Code
( )( )
Home Phone Number:Work Phone Number:
VOLUNTARY INFORMATION
The data requested in this section are voluntary and requested for statistical reasons for federal record keeping purposes only,CFR 29-4.B. This section
is not considered a part of the application. This sheet will be permanently separated from the rest of your application. It is the policy of the state, as
expressed in the Constitution, Statutes, Governor’s executive order and Personnel Board rules, that the work force of the state reflect the diversity of the
state.
ETHNICITY:
Check the ethnic group with which you identify. Check only one.
•
1 - Black, Non-Hispanic
•
2 - American Indian
•
3 - Asian/Pacific Islander
•
4 -Hispanic
•
5 - White, Non-Hispanic
GENDER:
Check the appropriate gender: Male Female
BIRTH DATE:
Some state jobs have a legally required minimum age. Please provide your BIRTH DATE only if you want to be considered for one of
those jobs.
Month: Day: Year:
VETERAN’S PREFERENCE INFORMATION:
State of Colorado agencies may be government contractors subject to the Vietnam Era Veterans’
Readjustment Assistance Act of 1974 (“VEVRA”), as amended, which requires government contractors to take affirmative action to employ and advance in employment
qualified disabled veterans and veterans of the Vietnam era covered by VEVRA. Under the Colorado Constitution, art. XII, sec.15, honorably discharged veterans, and
surviving spouses, are eligible for preference points when taking a competitive examination, other than a promotional examination.
If you are an honorably discharged veteran or unremarried widow/widower of a veteran who served on active duty in the United States Armed Forces during
one of the periods for which the federal government awards veteran’s preference points, you may claim points on your competitive examination for a
position with the state personnel system. Please attach a copy of a DD214 form and other supportive documentation for veteran’s points to be awarded to
your final passing score(s). If you are a current or previous state employee you cannot claim veteran’s preference points.
Check the appropriate veterans status:
•
1
-Disabled Veteran
• 2 - Veteran
• 3 -Disabled Vietnam Era Veteran•
4-Vietnam Era Veteran
• 5-Widow-Widower
COLORADO IS AN EQUAL OPPORTUNITY EMPLOYER
7/99Subject to revisions2
INSTRUCTIONS FOR COMPLETING APPLICATION FORM B
1.You must be a resident of Colorado at the time of application unless otherwise stated on the job
announcement that non-residents (residency waiver) may apply.
2.A separate application form must be submitted for each job announcement to which you are responding. Be
sure to include supporting documentation if requested on the announcement.
3.Write the state job title, class code and position number (if one appears) exactly as stated on the
announcement. Write your name and Social Security Number on each page where indicated.
4.Review the announcement carefully to determine if you meet the minimum qualifications as announced. Do
not apply if you do not meet the stated qualifications.
5.
It is your responsibility to assure that your application is receivedby the closing date in the location stated in
the announcement. Late applications may not be considered.
6.This application form and all attached documents are official records ofthe State and cannot be returned. All
information on pages 3-6 of this application, with the exception of Social Security Number and shaded
areasis considered public information under the State of Colorado Public Records Act.
7.Applicants are notified by mail oftheir status in the exam process. It is the applicant’s responsibility to notify
the agency to which this application is submitted of any change of address. Failure to do so may result in
improper notification for examinations, failure to be notified of job interview or removal of your name from an
eligible list.
8.If you are a current or previous permanent employee in the State Personnel System and would like to be
considered for transfer or reinstatement, complete this application form and write TRANSFER or
REINSTATEMENT across the front page. Submit the completed form to the agency to which you are
interested in transferring or being reinstated.
NOTE: TO BE CONSIDERED AS A TRANSFER/REINSTATEMENT, YOU MUST BE/HAVE BEEN AT THE
SAME LEVEL OR ABOVE AND MEET THE MINIMUM REQUIREMENTS AS STATED ON THE
ANNOUNCEMENT.
7/99Subject to revisions3
Name (Last, First Middle Initial, Suffix):Social Security Number:
COLORADO DRIVER’S LICENSE
Number:Class:Expiration Date:
Endorsements:Restrictions:
TYPE OF EMPLOYMENT DESIRED
Check any and all type(s) of employment you would accept:
•
2 - Full Time
• 3 - Temporary •
4 - Part-time
• 5 - Shift work
• 6 - Night work •
7 - Seasonal
• 8 - Nine Months
BACKGROUND CHECK
Many state jobs require a background check such as criminal record, driving record, credit check, etc. Would you be willing to submit to a background
check?•
YES•
NO
WORK LOCATIONS DESIRED
Indicate the locations where you will accept employment by placing the three digit code for the appropriate city or area in the boxes. The codes are listed
below. ONLY FIFTEEN (15) LOCATIONS MAY BE INDICATED. Your name will be referred only to positions in the locations you indicated. If you do
not accept a position offered in a location you indicate, your name will be removed from consideration for future job openings. The location codes you
select on this application apply only to the announcement to which you are responding.
LOCATION CODES:
DENVER: 860 - NORTHEAST DENVER 861 - NORTHWEST DENVER 812 - DOWNTOWN DENVER 844 - SOUTHEAST DENVER 845 - SOUTHWEST DENVER
201 - AGUILAR206 - COTOPAXI211 - GRANEROS CREEK134 - LOVELAND PASS569 - ROCKWOOD
401 - AKRON350 - CRAIG819 - GREELEY424 - LYONS839 - ROCKY FORD
550 - ALAMOSA305 - CRAWFORD820 - GREEN MTN RESVR560 - MANASSA220 - RYE
501 - ALLISON/ARBOLES554 - CREEDE313 - GUNNISON511 - MANCOS564 - SAGUACHE
801 - ALMONT306 - CRESTED BUTTE314 - GYPSUM124 - MATHESON840 - SALIDA
402 - ANTON207 - CRIPPLE CREEK525 - HARTSEL356 - MAYBELL841 - SAN LUIS
551 - ANTONITO406 - CROOK414 - HAXTON425 - MEAD565 - SARGENTS
802 - ARBOLES227 - CROWLEY353 - HAYDEN357 - MEEKER842 - SECURITY
101 - ARRIBA307 - DE BEQUE510 - HESPERUS319 - MESA127 - SEDALIA
803 - ARVADA111 - DEER TRAIL212 - HOLLY828 - MINTURN128 - SEIBERT
804 - ASPEN810 - DEL NORTE415 - HOLYOKE561 - MONARCH PASS817 - SILVERTHORNE\
403 - AULT308 - DELTA821 - HOMELAKE562 - MONTE VISTAFRISCO\ DILLON
102 - AURORA817 - DILLON/FRISCO/354 - HOT SULPHUR SPRGS320 - MONTROSE518 - SILVERTON
137 - AVON SILVERTHORNE315 - HOTCHKISS829 - MONUMENT362 - SKULL CREEK
103 - BAILEY811 - DINOSAUR416 - HUDSON125 - MORRISON566 - SOUTH PARK
301 - BASALT 506 - DOLORES118 - HUGO358 - MUDDY PASS221 - SPRINGFIELD
502 - BAYFIELD507 - DOVE CREEK119 - IDAHO SPRINGS426 - NEDERLAND363 - STEAMBOAT SPRINGS
503 - BEDROCK309 - DOWD JUNCTION417 - IDALIA427 - NEW RAYMER432 - STERLING
805 - BELLVUE 407 - DRAKE509 - IGNACIO831 - NORTHGLENN433 - STONEHAM
133 - BERTHOUD FALLS112 - DUMONT 418 - JOES512 - NORWOOD129 - STRASBURG
202 - BEULAH 508 - DURANGO419 - JOHNSTOWN513 - NUCLA222 - SUGAR CITY
104 - BLACKHAWK208 - EADS 420 - JULESBURG428 - NUNN434 - SUPERIOR
302 - BLUE MESA326 - EAGLE 213 - KIM833 - ORCHARD519 - TELLURIDE
404 - BOULDER 351 - ELK SPRINGS120 - KIOWA834 - ORDWAY846 - THORNTON
105 - BRECKENRIDGE113 - EMPIRE 121 - KIT CARSON429 - OTIS223 - TRINIDAD
601 - BRIGHTON 815 - ENGLEWOOD 122 - KITTREDGE514 - OURAY323 - TWIN LAKES
806 - BROOMFIELD408 - ESTES PARK355 - KREMMLING430 - OVID130 - VAIL
405 - BRUSH 132 - EVERGREEN558 - LA MANGA PASS515 - PAGOSA SPRINGS567 - VILLA GROVE
552 - BUENA VISTA 816 - FAIRPLAY822 - LA JARA835 - PALISADE364 - WALDEN
106 - BURLINGTON440 - FLORENCE 216 - LA VETA321 - PAONIA224 - WALSENBURG
203 - CALHAN 556 - FORT GARLAND214 - LA JUNTA322 - PARACHUTE435 - WELLINGTON
204 - CANON CITY209 - FOWLER526 - LA VETA PASS117 - PARKER 225 - WESTCLIFFE
303 - CARBON DALE 115 - FRANKTOWN823 - LAKE GEORGE218 - PENROSE848 - WESTMINSTER
504 - CASCADE MOLAS PASS817 - FRISCO / DILLON 316 - LAKE CITY837 - PITKIN 849 - WHEATRIDGE
107 - CASTLE ROCKSILVERTHORNE824 - LAKEWOOD836 - PLATTEVILLE 436 - WIGGINS
304 - CEDAREDGE 411 - FT MORGAN215 - LAMAR563 - PONCHA SPRINGS131 - WINTER PARK
807 - CENTRAL CITY 410 - FT LUPTON 217 - LAS ANIMAS431 - POUDRE RIVER CANYON324 - WOLCOTT
108 - CHEYENNE WELLS409 - FT COLLINS825 - LATHROP219 - PUEBLO568 - WOLF CREEK PASS
109 - COALCREEK 310 - GATEWAY317 - LEADVILLE126 - PUNKIN CENTER (EAST)
553 - COCHETOPA PASS116 - GEORGETOWN123 - LIMON359 - RABBIT EARS PASS520 - WOLF CREEK PASS
197 - COLLBRAN 412 - GILCREST 826 - LITTLETON838 - RAMAH (WEST)
205 - COLORADO SPRINGS311 - GLENWOOD SPRINGS421 - LIVERMORE360 - RANGELY226 - WOODLAND PARK
808 - COMMERCE CITY818 -GOLDEN 318 - LOMA516 - RICO437 - WRAY
809 - CONEJOS210 - GRANADA422 - LONGMONT517 - RIDGEWAY365 - YAMPA
110 - CONIFER352 - GRANBY 423 - LOVELAND361 - RIFLE438 - YUMA
505 - CORTEZ312 - GRAND JUNCTION
7/99Subject to revisions4
Name (Last, First, Middle Initial, Suffix):Social Security Number:
LICENSES/CERTIFICATION/REGISTRATIONS
If a license/certificate/registration is required for the job for which you are applying (e.g., Journeyman Plumber, Professional Engineer, etc.) complete the following
Professional/Speciality License Type:License Number:
Expiration Date:State and/or Agency Granting License:
LANGUAGE PROFICIENCY
List other language skills you have and your level of proficiency (speak, read, write, etc.).
EDUCATION AND EMPLOYMENT HISTORY
This section must be accurate and complete. The application is used to determine if you meet the minimum qualifications as published in the
job announcement. The application may also be used to determine the highest qualified individuals to be invited to the next step in the
selection process. Applicants omitting sufficient information may not be invited to the next step of the selection process or may be rejected.
EDUCATION RECORD
High School Graduate:Date:GED:Date:
•
Yes
•
No
•
Yes
•
No
UNIVERSITY and COLLEGE (UNDERGRADUATE, GRADUATE, POST GRADUATE)
Name:Location:Attended: From -To (Mo - Yr)
Degree Awarded:Date:Major Field of Study:Minor Field of Study:Total Semester Hours:
Name:Location:Attended: From -To (Mo - Yr)
Degree Awarded:Date:Major Field of Study:Minor Field of Study:Total Semester Hours:
Name:Location:Attended: From -To (Mo - Yr)
Degree Awarded:Date:Major Field of Study:Minor Field of Study:Total Semester Hours:
BUSINESS, TRADE, TECHNICAL, VOCATIONAL SCHOOL OR MILITARY TRAINING
Name:Location:Attended: From -To (Mo - Yr)
Title of Program or Subjects Taken:Total Classroom Hrs:Date:
Cert. Rcvd.
•
Yes
•
No
Name:Location:Attended: From -To (Mo - Yr)
Title of Program or Subjects Taken:Total Classroom Hrs:Date:
Cert. Rcvd.
•
Yes
•
No
7/99Subject to revisions5
Name (Last, First, Middle Initial, Suffix):Social Security Number:
EMPLOYMENT HISTORY
List your employment history starting with the most recent job, including part-time, temporary, and volunteer jobs. If more than one job was
held with a given organization, list each job held asa separate period of employment. Under “Duties”, describeclearly the tasks you performed
and the nature of your supervisory, technical, or other responsibilities as theyrelate to the job for which you are applying. Be complete and
specific in detailing of duties. Information must be accurate. If it is found that information provided is untrue or falsified, you will not be
considered for a job with the State of Colorado and/or may be removed from a job after hire. If you need more space attach a separate sheet
of paper usingthe same format.
EMPLOYER/Kind of Business:Your Title:DATES OF
EMPLOYMENT
Address (Street, City, State, ZIP Code):
From: Mo Yr
Supervisor Name:Title:Phone:
To: Mo Yr
Duties: (List major duties and responsibilities relevant to the job for which applying; be specific)
Hrs. Per Week:
Monthly Salary $
Number of Employees
Supervised:
Professional:
Non-Professional:
Reason for leaving or seeking other employment:
EMPLOYER/Kind of Business:Your Title:DATES OF
EMPLOYMENT
Address (Street, City, State, ZIP Code):
From: Mo Yr
Supervisor Name:Title:Phone:
To: Mo Yr
Duties: (List major duties and responsibilities relevant to the job for which applying; be specific)
Hrs. Per Week:
Monthly Salary $
Number of Employees
Supervised:
Professional:
Non-Professional:
Reason for leaving or seeking other employment:
