Fillable Printable State of Colorado Employment Application Form
Fillable Printable State of Colorado Employment Application Form
State of Colorado Employment Application Form
7/99 Subject to revisions 1
STATE OF COLORADO
EMPLOYMENT APPLICATION FORM B
SUBMIT COMPLETED FORM TO 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
7/99 Subject to revisions 2
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 received by 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 of the State and cannot be returned. All
information on pages 3-6 of this application, with the exception of Social Security Number and shaded
areas is considered public information under the State of Colorado Public Records Act.
7. Applicants are notified by mail of their 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.
7/99 Subject to revisions 3
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 - AGUILAR 206 - COTOPAXI 211 - GRANEROS CREEK 134 - LOVELAND PASS 569 - ROCKWOOD
401 - AKRON 350 - CRAIG 819 - GREELEY 424 - LYONS 839 - ROCKY FORD
550 - ALAMOSA 305 - CRAWFORD 820 - GREEN MTN RESVR 560 - MANASSA 220 - RYE
501 - ALLISON/ARBOLES 554 - CREEDE 313 - GUNNISON 511 - MANCOS 564 - SAGUACHE
801 - ALMONT 306 - CRESTED BUTTE 314 - GYPSUM 124 - MATHESON 840 - SALIDA
402 - ANTON 207 - CRIPPLE CREEK 525 - HARTSEL 356 - MAYBELL 841 - SAN LUIS
551 - ANTONITO 406 - CROOK 414 - HAXTON 425 - MEAD 565 - SARGENTS
802 - ARBOLES 227 - CROWLEY 353 - HAYDEN 357 - MEEKER 842 - SECURITY
101 - ARRIBA 307 - DE BEQUE 510 - HESPERUS 319 - MESA 127 - SEDALIA
803 - ARVADA 111 - DEER TRAIL 212 - HOLLY 828 - MINTURN 128 - SEIBERT
804 - ASPEN 810 - DEL NORTE 415 - HOLYOKE 561 - MONARCH PASS 817 - SILVERTHORNE\
403 - AULT 308 - DELTA 821 - HOMELAKE 562 - MONTE VISTA FRISCO\ DILLON
102 - AURORA 817 - DILLON/FRISCO/ 354 - HOT SULPHUR SPRGS 320 - MONTROSE 518 - SILVERTON
137 - AVON SILVERTHORNE 315 - HOTCHKISS 829 - MONUMENT 362 - SKULL CREEK
103 - BAILEY 811 - DINOSAUR 416 - HUDSON 125 - MORRISON 566 - SOUTH PARK
301 - BASALT 506 - DOLORES 118 - HUGO 358 - MUDDY PASS 221 - SPRINGFIELD
502 - BAYFIELD 507 - DOVE CREEK 119 - IDAHO SPRINGS 426 - NEDERLAND 363 - STEAMBOAT SPRINGS
503 - BEDROCK 309 - DOWD JUNCTION 417 - IDALIA 427 - NEW RAYMER 432 - STERLING
805 - BELLVUE 407 - DRAKE 509 - IGNACIO 831 - NORTHGLENN 433 - STONEHAM
133 - BERTHOUD FALLS 112 - DUMONT 418 - JOES 512 - NORWOOD 129 - STRASBURG
202 - BEULAH 508 - DURANGO 419 - JOHNSTOWN 513 - NUCLA 222 - SUGAR CITY
104 - BLACKHAWK 208 - EADS 420 - JULESBURG 428 - NUNN 434 - SUPERIOR
302 - BLUE MESA 326 - EAGLE 213 - KIM 833 - ORCHARD 519 - TELLURIDE
404 - BOULDER 351 - ELK SPRINGS 120 - KIOWA 834 - ORDWAY 846 - THORNTON
105 - BRECKENRIDGE 113 - EMPIRE 121 - KIT CARSON 429 - OTIS 223 - TRINIDAD
601 - BRIGHTON 815 - ENGLEWOOD 122 - KITTREDGE 514 - OURAY 323 - TWIN LAKES
806 - BROOMFIELD 408 - ESTES PARK 355 - KREMMLING 430 - OVID 130 - VAIL
405 - BRUSH 132 - EVERGREEN 558 - LA MANGA PASS 515 - PAGOSA SPRINGS 567 - VILLA GROVE
552 - BUENA VISTA 816 - FAIRPLAY 822 - LA JARA 835 - PALISADE 364 - WALDEN
106 - BURLINGTON 440 - FLORENCE 216 - LA VETA 321 - PAONIA 224 - WALSENBURG
203 - CALHAN 556 - FORT GARLAND 214 - LA JUNTA 322 - PARACHUTE 435 - WELLINGTON
204 - CANON CITY 209 - FOWLER 526 - LA VETA PASS 117 - PARKER 225 - WESTCLIFFE
303 - CARBON DALE 115 - FRANKTOWN 823 - LAKE GEORGE 218 - PENROSE 848 - WESTMINSTER
504 - CASCADE MOLAS PASS 817 - FRISCO / DILLON 316 - LAKE CITY 837 - PITKIN 849 - WHEATRIDGE
107 - CASTLE ROCK SILVERTHORNE 824 - LAKEWOOD 836 - PLATTEVILLE 436 - WIGGINS
304 - CEDAREDGE 411 - FT MORGAN 215 - LAMAR 563 - PONCHA SPRINGS 131 - WINTER PARK
807 - CENTRAL CITY 410 - FT LUPTON 217 - LAS ANIMAS 431 - POUDRE RIVER CANYON 324 - WOLCOTT
108 - CHEYENNE WELLS 409 - FT COLLINS 825 - LATHROP 219 - PUEBLO 568 - WOLF CREEK PASS
109 - COALCREEK 310 - GATEWAY 317 - LEADVILLE 126 - PUNKIN CENTER (EAST)
553 - COCHETOPA PASS 116 - GEORGETOWN 123 - LIMON 359 - RABBIT EARS PASS 520 - WOLF CREEK PASS
197 - COLLBRAN 412 - GILCREST 826 - LITTLETON 838 - RAMAH (WEST)
205 - COLORADO SPRINGS 311 - GLENWOOD SPRINGS 421 - LIVERMORE 360 - RANGELY 226 - WOODLAND PARK
808 - COMMERCE CITY 818 -GOLDEN 318 - LOMA 516 - RICO 437 - WRAY
809 - CONEJOS 210 - GRANADA 422 - LONGMONT 517 - RIDGEWAY 365 - YAMPA
110 - CONIFER 352 - GRANBY 423 - LOVELAND 361 - RIFLE 438 - YUMA
505 - CORTEZ 312 - GRAND JUNCTION
7/99 Subject to revisions 4
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
7/99 Subject to revisions 5
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 as a separate period of employment. Under “Duties”, describe clearly the tasks you performed
and the nature of your supervisory, technical, or other responsibilities as they relate 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 using the 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:
