INSTRUCTIONS FOR COMPLETING AND SUBMITTING THE

STATE OF CONNECTICUT
APPLICATION FOR EXAMINATION OR EMPLOYMENT (FORM CT-HR-12)
PLEASE READ CAREFULLY BEFORE COMPLETING THE APPLICATION

GENERAL INFORMATION AND INSTRUCTIONS

This application form is the official State of Connecticut Application Form for Examination or Employment effective October 1,
2010. PLD-1 application forms should not be used on or after October 1, 2010. Check the State Employment Pages on the
DAS website (www.das.state.ct.us/exam) for more detailed information about completing the State Application Form and about
state examinations, job opportunities and to sign up for e-mail notification of current exams and job openings.
1. The CT-HR-12 is a PDF document that can be completed on-line or it can be printed and completed manually. If you
complete the form on-line, you can save it in your documents for future reference.
2. This application form can be used to apply for currently posted State of Connecticut examinations or currently posted
job opportunities (positions/job postings). If you are applying for a currently posted examination, make certain you
include the examination title and examination number. If you are applying for a currently posted job/position, make
certain you include the position title and position number.
3. Type or print (in ink) all information requested on the application form. It is critical that you complete all sections of the
application form and that all of the information you provide is true and accurate.
4. Give complete and accurate information about your education, work experiences and licenses/certifications as it
relates to the minimum requirements for the examination or position for which you are applying. The information you
provide on your application form will be used to determine if you meet the requirements as outlined on the examination
announcement or position posting. (Resumes may be included as a supplement to the application form, but they will
not substitute for any information required on the application form.)
5. Write your name and examination or position title on the top of all pages of your application form. Write your social
security number on the top of Page 1.
6. Sign and date Section 3 of your application form (a typed name will substitute for a handwritten signature).
7. Make a copy of your application package for your records before submission.
8. Do NOT submit this page with your application package.
9. Application packages sent to an incorrect address/fax will not be accepted. Carefully review the application filing
instructions on the examination announcement or the position posting to ensure your application materials are sent to
the correct location.
10. Late and/or incomplete application packages will not be accepted.

INSTRUCTIONS IF YOU ARE APPLYING FOR A CURRENTLY POSTED EXAMINATION

1. Obtain a copy of the examination announcement before completing this application. The announcement includes important
information such as: the examination title and number, minimum requirements for admission to the examination, closing date
for the application package, and other job-related information. In many cases the exam announcement also contains special
filing instructions which detail exam materials that must be submitted with the application form. Examination announcements
can be obtained from the DAS website (http://www.das.state.ct.us/exam). Follow all application and examination instructions
very carefully!
2. A separate application form must be submitted for each examination for which you are applying.
3. Applications (and supplemental exam materials, if required) for examinations are always submitted to the Statewide Human
Resources Management Division at the Department of Administrative Services. Refer to the examination announcement for
the mailing address and secure fax number for submitting your application form (and exam materials, if required). If faxing
materials make certain that your application form is complete and transmitted correctly and without error. Incomplete faxes
or faxes received blank because pages were faxed upside down will not be accepted.
4. Applications received for which there is no current examination announcement are not accepted.
5. This application is not to be used for the following examinations: State Police Trooper Trainee, Correction Officer, Protective
Services Trainee (Police) and State Marshall. When these examinations are open you will find special Internet application
forms on the DAS website (http://www.das.state.ct.us/exam).

INSTRUCTIONS IF YOU ARE APPLYING FOR A CURRENTLY POSTED JOB/POSITION

1. Obtain a copy of the job/position posting before completing this application. The posting includes important information such
as: the position title and position number, minimum requirements for the position, closing date for applications, and other job-
related information. The posting also contains application filing instructions which detail what documents need to be
submitted to apply for the position and where and how to submit your application package. Follow all application filing
instructions very carefully!
2. A separate application form must be submitted for each position you are applying for.
3. Applications are only accepted for currently posted positions.
4. Applications for positions are to be sent to the hiring agency. They are not to be sent to the Department of Administrative
Services, unless the position posting specifically directs you to do so.
 0 4 6 7 8 0 7 5 6
APPLICATION FOR EXAMINATION SOCIAL SECURITY NUMBER: ____ ____ ____ -____ ____ - ____ ____ ____ ____
OR EMPLOYMENT CT-HR-12 NEW 10/20/2010
(formerly Form PLD-1) Harris
________________________________________ Jordan
_______________________ E
____
Last Name First Name MI

STATE OF CONNECTICUT
Application for Examination or Employment (CT-HR-12)
DO NOT WRITE APPROVED________ DISAPPROVED________ REVIEWED BY: __________ AE Date: __________
in shaded area
GE – Lack GE LS – Length SE GS – Length GE, Lack SE AS – No Agency Status SI – No Supp Exam Mat.
LG – Length GE ET – Lack GE, SE EM – Not Current St Emp ST – No Classified Status II – Insufficient Info
SE – Lack SE LL – Length GE, SE AR – Emp not Hiring Agency CS – Status in Class LT – Late

INSTRUCTIONS TO APPLICANT: Read the detailed instructions on the first page of this application
and on the examination announcement or position/job posting before completing this application form.
Type or print answers to ALL questions.

SECTION 1: APPLICANT CONTACT INFORMATION

Harris
______________________________ Jordan
_____________________ E
___ ______
LAST NAME FIRST NAME MI SUFFIX (i.e., Jr., MD, Ph.D.)

68 Virginia ave
_________________________________________________________ 19
____________________
MAILING ADDRESS (P.O. Box # or house number and street) APARTMENT # (if any)

Danbury
_______________________________________________ CT
______ 06810
_________________
CITY STATE ZIP CODE

List other name(s) you have used. Include last name, first name and middle initial for each.
_____________________________________ ______________________________________

203 790 1975

(____)______-________ 203 740 7623
(____)______-________ ✔
May we call you at work? __Yes __No
HOME PHONE # BUSINESS PHONE #

203 768 5480

(____)______-________ [email protected]
_______________________________________________
CELL PHONE # E-MAIL ADDRESS

SECTION 2: PURPOSE OF APPLICATION (CHECK ONE):

___ STATE EXAMINATION ✔ STATE POSITION/JOB POSTING

___

Complete the required information below for one examination OR one position ONLY:

If you are applying for a State of Connecticut examination complete the following information as it
appears on the examination announcement:
Examination Title: ___________________________________________ Exam No.: _____________

OR
If you are applying for a State of Connecticut position/job complete the following information as it
appears on the posting.
PUBLIC SAFETY DISPATCHER TRAINEE
Position/Job Title: ______________________________________ 6391
Job Posting No.: ___________
 Harris Jordan E
PAGE TWO ________________________________________ _______________________ ____
Last Name First Name MI
______________________________________________________________________
Examination Title or Position Title

SECTION 3 APPLICANT CERTIFICATION

SIGNATURE REQUIRED: By signing or typing my name on the signature line below, I am certifying
that the statements made by me on this application form and attachments, if any, are true and
complete to the best of my knowledge and are made in good faith. I understand that if I knowingly
make any misstatement of fact, I am subject to disqualification and dismissal and to such other
penalties as may be prescribed by law or personnel regulations. All statements made on this
application, including employment information, are subject to verification as a condition of
employment.

Applicant signature: Jordan Harris

__________________________________ Date: ____________
(Signature is required)
Note: A typed name will substitute for a handwritten signature.

SECTION 4: STATE EMPLOYMENT HISTORY (To be completed by current or former State of CT

employees)

Are you a current State of Connecticut employee? __Yes ✔

__No If ‘Yes: __________________
6-digit Employee ID #
_____________________________________ _________________________________________
Official Job Class Title Employing Agency, Department, College/University

If you are not a current State of Connecticut employee but worked for the State of Connecticut
previously, did you leave State service within the past 10 years? __Yes __No

If ‘Yes’ complete dates of employment from: ____/____/_______to ____/____/_______

MM DD YYYY MM DD YYYY
_____________________________________ _________________________________________
Official Job Class Title at time of separation Employing Agency, Department, College/University

Reason for leaving: ________________________________________________________________

SECTION 5: APPLICANT EDUCATION

A. Primary and Secondary Education

Have you graduated from high school or received a high school equivalency diploma (GED)?
✔
__Yes __No
 PAGE THREE
Harris Jordan
________________________________________ _______________________ ____
E
Last Name First Name MI
______________________________________________________________________
Examination Title or Position Title
SECTION 5: APPLICANT EDUCATION (continued)

B. College Education

Johnson &Wales University

1.) ______________________________________ Providence
______________________ RI
___ __________
Name of College or University Attended City State Country*

Is this college accredited**? ✔

__Yes __No 09 2003 11 2004
Dates of Attendance: From: ___/_____To:___/_____
(MM/YYYY) (MM/YYYY)

Type of degree completed: __Associate __Bachelor __Master __Doctorate __Law ✔

__None
20
If ‘None’ please indicate the number of credit hours completed: ____

If a degree was conferred, complete the following information for this college/university:
culinary arts
_____________________________________ ________________________________________
Major Course of Study Major Course of Study (only if double major)

Naugatuck Valley Community College

2.) ______________________________________ Waterbury
______________________ CT
___ __________
Name of College or University Attended City State Country*

✔
Is this college accredited**? __Yes __No 09 2009 12 2010
Dates of Attendance: From: ___/_____To:___/_____
(MM/YYYY) (MM/YYYY)

Type of degree completed: __Associate __Bachelor __Master __Doctorate __Law ✔

__None
If ‘None’ please indicate the number of credit hours completed: ____

If a degree was conferred, complete the following information for this college/university:
criminal justice
_____________________________________ ________________________________________
Major Course of Study Major Course of Study (only if double major)

3.) ______________________________________ ______________________ ___ __________

Name of College or University Attended City State Country*

Is this college accredited**? __Yes __No Dates of Attendance: From: ___/_____To:___/_____

(MM/YYYY) (MM/YYYY)

Type of degree completed: __Associate __Bachelor __Master __Doctorate __Law __None

If ‘None’ please indicate the number of credit hours completed: ____

If a degree was conferred, complete the following information for this college/university:
_____________________________________ ________________________________________
Major Course of Study Major Course of Study (only if double major)

Attach additional sheets (labeled with “Section 5 – continued” and include your name and examination
number/title or position title in upper right corner) if you attended more than three (3) colleges/universities.
* - If the institution of higher learning is located outside of the United States, you are responsible for providing documentation from a recognized USA
accrediting service which specializes in determining foreign education equivalencies. The responsibility for and the costs associated with obtaining this
equivalency information rest with you, the applicant.
** - In order to receive educational credit towards admittance to an examination, the institution must be recognized by the CT Department of Higher
Education as an accredited institution (www.chea.org).
 Harris Jordan E
PAGE FOUR ________________________________________ _______________________ ____
Last Name First Name MI
______________________________________________________________________
Examination Title or Position Title

SECTION 5: APPLICANT EDUCATION (continued)

C. Technical, Business or Other Education

1.) ______________________________________ ______________________ ___ __________

Name of School Attended City State Country*

Dates of Attendance: From: _____/_____To:_____/_____ ________________________________

(MM/YYYY) (MM/YYYY) Type of degree or certificate earned

2.) ______________________________________ ______________________ ___ __________

Name of School Attended City State Country*

Dates of Attendance: From: _____/_____To:_____/_____ ________________________________

(MM/YYYY) (MM/YYYY) Type of degree or certificate earned

SECTION 6: REQUIRED LICENSES, CERTIFICATIONS AND OTHER

1. Do you have any valid licenses or certificates which authorize you to practice a profession or trade? (e.g.
law, nursing, psychology, plumbing, etc.) ___Yes ✔
___No

If yes, please complete the following section:

A.) Type of License: ________________ License #: ____________ Issued By: ___________

Date Issued: ____/____ Expiration Date: ____/____

(MM/YY) (MM/YY)

B.) Type of License: ________________ License #: ____________ Issued By: ___________

Date Issued: ____/____ Expiration Date: ____/____

(MM/YY) (MM/YY)
CT
2. Do you currently have a valid Motor Vehicle Driver’s License (Class D)? ✔
__Yes __No State: ______

3. Do you have any endorsements to your Class D license? If so which ones? __________________

4. Do you currently have a valid Commercial Driver’s License (CDL)? __Yes ✔

__No State: _______

If you have a CDL what class? ____Class A ____Class B ____Class C

English
5. What languages do you speak, read, write or sign fluently? _______________________________

_____________________________________________________________________________________
 PAGE FIVE
Harris Jordan
________________________________________ _______________________ ____
E
Last Name First Name MI
______________________________________________________________________
Examination Title or Position Title

SECTION 7: EMPLOYMENT HISTORY

Important Instructions for Completing this Section. Beginning with your PRESENT or MOST RECENT employment
or volunteer experience and working backward, list all positions held that you wish to be considered toward meeting the
eligibility requirements (minimum qualifications) stated on the exam announcement or job posting. List all positions (job
titles) separately, even if with the same employer. Provide the starting and ending dates (month, day and year) of
your employment for each position and indicate if the position was full or part time and the number of hours worked per
week. Clearly describe the work (duties) you personally performed in each position. If a job included a mixture of relevant
duties and other duties that are not relevant toward meeting the eligibility requirements, specify the percentage of time
spent performing each duty. Number your jobs, starting with your most recent job as number 1. Make additional copies
of this page as needed to list additional positions, and continue the number sequence. If you need additional space
for the descriptions of your duties for one or more positions, attach an 8 1/2” x 11” sheet with your name and the exam
number or position title and continue the descriptions of your duties, using the number sequence to identify which
positions the duties belong to. You must fill out this application completely even if you attach a resume. Failure to
provide all of the REQUIRED information for each position (or job title) held may result in your application being
disapproved. Although a resume can be attached, only jobs included in this section of the application form will be
considered when determining if you meet the required minimum qualifications for the exam or position for which you are
applying.

Stocker/Cashier Costco Wholesale

POSITION 1: ________________________________________ _____________________________________________
Most Recent Official Job Title Company Name/Department where assigned
200 Federal Rd
_________________________________________________
Brookfield
____________________
CT
_______
06804
____________
Business Address (P.O. Box or # and Street) City State Zip Code
Wholesale
___________________________________________
floor manager
_________________________________________________
Type of Business Official Job Title of Immediate Supervisor
07 11 05 present
Dates of Employment: From: ___/____/____To:___________
(203) 740-7623
Phone Number: ________________________
(MM/DD/YY) (MM/DD/YY 18.00 per hour
Annual Salary/Hourly Wage: ______________
or Present)

✔ Full-time
This job is/was: ___ ___ Part-time ____ Per Diem
38
Number of Hours Worked per week: _______

Number & Job Titles of Employees Supervised by you: ____________________________________________________

still employed
Reason for leaving: ________________________________________________________________

List all major duties and responsibilities performed by you in this job. (This area must be completed for each job listed.)

Place merchandise on store shelves, pegs and overstock in stockroom.

Insure bin tags are properly placed and shelves faced.
Attach signage to shelves and pegs.
Assist in setting up or reorganizing product displays.
Answer basic customer questions while on the floor.
May assist in transporting purchases to customer vehicles.
Other duties as assigned.
 Harris Jordan E
PAGE SIX ________________________________________ _______________________ ____
Last Name First Name MI
______________________________________________________________________
SECTION 7: EMPLOYMENT HISTORY (CONTINUED) Examination Title or Position Title

POSITION 2: ________________________________________ _____________________________________________

Official Job Title Company Name/Department where assigned

_________________________________________________ ____________________ _______ ____________

Business Address (P.O. Box or # and Street) City State Zip Code

___________________________________________ _________________________________________________
Type of Business Official Job Title of Immediate Supervisor

Dates of Employment: From: ___/____/____To:___/____/____ Phone Number: ________________________

(MM/DD/YY) (MM/DD/YY) Annual Salary/Hourly Wage: ______________

This job is/was: ___ Full-time ___ Part-time ____ Per Diem Number of Hours Worked per week: _______

Number & Job Titles of Employees Supervised by you: ____________________________________________________

Reason for leaving: ________________________________________________________________

List all major duties and responsibilities performed by you in this job. (This area must be completed for each job listed.)

POSITION 3: ________________________________________ _____________________________________________

Official Job Title Company Name/Department where assigned

_________________________________________________ ____________________ _______ ____________

Business Address (P.O. Box or # and Street) City State Zip Code

___________________________________________ _________________________________________________
Type of Business Official Job Title of Immediate Supervisor

Dates of Employment: From: ___/____/____To:___/____/____ Phone Number: ________________________

(MM/DD/YY) (MM/DD/YY) Annual Salary/Hourly Wage: ______________

This job is/was: ___ Full-time ___ Part-time ____ Per Diem Number of Hours Worked per week: _______

Number & Job Titles of Employees Supervised by you: ____________________________________________________

Reason for leaving: ________________________________________________________________

List all major duties and responsibilities performed by you in this job. (This area must be completed for each job listed.)
 Harris Jordan E
PAGE SEVEN ________________________________________ _______________________ ____
Last Name First Name MI
______________________________________________________________________
SECTION 7: EMPLOYMENT HISTORY (CONTINUED) Examination Title or Position Title

POSITION 4: ________________________________________ _____________________________________________

Official Job Title Company Name/Department where assigned

_________________________________________________ ____________________ _______ ____________

Business Address (P.O. Box or # and Street) City State Zip Code

___________________________________________ _________________________________________________
Type of Business Official Job Title of Immediate Supervisor

Dates of Employment: From: ___/____/____To:___/____/____ Phone Number: ________________________

(MM/DD/YY) (MM/DD/YY) Annual Salary/Hourly Wage: _______________

This job is/was: ___ Full-time ___ Part-time ____ Per Diem Number of Hours Worked per week: _______

Number & Job Titles of Employees Supervised by you: ____________________________________________________

Reason for leaving: ________________________________________________________________

List all major duties and responsibilities performed by you in this job. (This area must be completed for each job listed.)

POSITION 5: ________________________________________ _____________________________________________

Official Job Title Company Name/Department where assigned

_________________________________________________ ____________________ _______ ____________

Business Address (P.O. Box or # and Street) City State Zip Code

___________________________________________ _________________________________________________
Type of Business Official Job Title of Immediate Supervisor

Dates of Employment: From: ___/____/____To:___/____/____ Phone Number: ________________________

(MM/DD/YY) (MM/DD/YY) Annual Salary/Hourly Wage: _______________

This job is/was: ___ Full-time ___ Part-time ____ Per Diem Number of Hours Worked per week: _______

Number & Job Titles of Employees Supervised by you: ____________________________________________________

Reason for leaving: ________________________________________________________________

List all major duties and responsibilities performed by you in this job. (This area must be completed for each job listed.)

PAGE EIGHT ________________________________________ _______________________ ____

 PAGE EIGHT Harris
________________________________________ Jordan
_______________________
E
____
Last Name First Name MI
______________________________________________________________________
SECTION 8: VETERAN’S PREFERENCE Examination Title or Position Title

Any veteran who served in the armed forces of the Unites States (i.e., United States Army, Navy, Marine Corps,
Coast Guard and Air Force) during time of war and was honorably discharged from, or released under honorable
conditions from active service may be eligible for Veterans’ credit. Time of war periods include: 12/7/1941 to
12/31/1947; 6/27/50 to 1/31/55; 7/1/58 to 11/1/58; 2/28/61 to 7/1/75; 9/29/82 to 3/30/84; 10/25/83 to 12/15/83;
2/1/87 to 7/23/87; 12/20/89 to 1/31/90; and 8/2/90 to the present. “Service in time of war” means service of ninety or
more cumulative days except if the war, campaign or other operation lasted less than ninety days in which case, it
means service for the entire period of the war. If you are claiming Veteran’s Preference points check one of the
options below. If you are not claiming Veteran’s Preference points go on to Section 9.

Do you claim Veteran’s Preference (5 points)?

__ A. As a veteran (as defined above) who is not eligible for disability compensation or pension from the United
States through the Veterans’ Administration. (Documents: 1)
__ B. As a spouse of such veteran who is not eligible for disability compensation or pension from the United
States through the Veterans’ Administration and, who by reason of such veterans’ disability is unable to
pursue gainful employment. (Documents: 2, 3 and 4)
__ C. As an unmarried surviving spouse of such veteran who is not eligible for disability compensation or
pension from the United States through the Veterans’ Administration. (Documents: 2, 3, 5, 6)

You may also be eligible for Veteran’s Preference (5 points), if:

__ A. You have been honorably discharged or released under honorable conditions from active service in the
armed forces of the United States and have served in a military action for which you received or were
entitled to receive a campaign badge or expeditionary medal. (Documents: 1)

Disabled Veteran’s Preference (10 points)?

__ A. As a disabled veteran (as defined above) who is eligible for disability compensation or pension from the
United States through the Veterans’ Administration. (Documents: 1, 7)
__ B. As a spouse of a disabled veteran who is eligible for disability compensation or pension from the United
States through the Veterans’ Administration, and who is unable to pursue gainful employment due to the
veteran’s disability. (Documents: 2, 3, 4, 7)
__ C. As an unmarried surviving spouse of a disabled veteran who is eligible for disability compensation or
pension from the United States through the Veterans’ Administration. (Documents: 2, 5, 6, 8)

Documentation Required. Please refer to the “Documentation Required” listed after each category above to
determine the specific documentation you are required to submit in order to be eligible to receive Veteran’s
preference points if you pass an open competitive examination.

1. DD214 – Member-4 copy for self showing: honorable discharge or release under honorable conditions from
active service in the armed forces, dates of entry into and separation of service, and campaign badge or
expeditionary medal earned (if applicable).
2. DD214 – Member-4 copy for spouse showing honorable discharge or release under honorable conditions
from active service in the armed forces, dates of entry into and separation of service.
3. Marriage Certificate.
4. Statement from spouse’s physician certifying that s/he is unable to pursue gainful employment because of
disability.
5. Death certificate for spouse or official notice of his/her death if it occurred in the line of duty.
6. Statements from two disinterested persons that widow/widower has not remarried.
7. Statement from Veterans’ Administration dated within the past six months certifying that the veteran is
currently eligible for compensation or pension benefits.
8. Statement from Veterans’ Administration certifying that the veteran was eligible to receive disability
compensation or pension benefits at the time of his/her death.

Check one if you are claiming Veteran’s Preference:

___ Proof (required documents) previously submitted ___ Proof attached to this application

Note: Veteran’s points are only added after a candidate passes an open competitive examination. (C.G.S. 5-224)
 Harris Jordan E
PAGE NINE ________________________________________ _______________________ ____
Last Name First Name MI
______________________________________________________________________
Examination Title or Position Title
SECTION 9: POSITION INFORMATION

What type(s) of position(s) will you consider? Answer both 1 and 2.

1. __Full-Time only __ Part-Time only ✔ Either Part-time or Full-time

___
✔
2. __Permanent only __Nonpermanent only ___ Either Permanent or Nonpermanent

What shift would you be willing to work? Check all that apply:
✔
____Day (First Shift) ✔ Evening (Second Shift)
____ ✔ Night (Third Shift)
____ ✔
____Weekends

SECTION 10: EMPLOYMENT DISTRICTS

Check the box(es) for ONLY the district(s) in which you will accept employment. Indicate your choice of
location preference(s) in the left hand column by checking the appropriate box(es) where you are willing to
work. Not all jobs are used in all locations. Names will be certified by location at the request of the
appointing authority.

✔ A
__ All Locations
__ B Greenwich, Stamford, New Canaan, Darien
__ C Norwalk, Wilton, Weston, Westport
__ D Fairfield, Easton, Monroe, Trumbull, Shelton, Stratford, Milford
__ E Bridgeport
__ F Redding, Ridgefield, Danbury, Bethel, Newton, Brookfield, New Fairfield, Bridgewater, Sherman,
New Milford, Roxbury, Washington, Kent, Warren
__ G Morris, Litchfield, Harwinton, New Hartford, Torrington, Goshen, Cornwall, Sharon, Salisbury,
Canaan, North Canaan, Norfolk, Colebrook, Winchester, Hartland, Barkhamsted
__ H Thomaston, Bethlehem, Watertown, Woodbury, Southbury, Middlebury, Beacon Falls, Naugatuck,
Prospect, Waterbury, Wolcott, Cheshire
__ I Oxford, Seymour, Ansonia, Derby
__ J West Haven, Orange, Woodbridge, Bethany, Hamden, North Haven, East Haven, North Branford,
Wallingford, Branford, Guilford, Madison, Clinton
__ K New Haven
__ L Meriden
__ M Plymouth, Bristol, Burlington
__ N Berlin, Southington, Plainville, New Britain
__ O Avon, Farmington, West Hartford
__ P East Hartford, Manchester
__ Q Hartford
__ R Granby, Canton, Simsbury, Suffield, East Granby, Windsor Locks, Windsor, Bloomfield, East
Windsor, South Windsor, Ellington, Vernon, Tolland, Stafford, Willington
__ S Enfield, Somers
__ T Newington, Wethersfield, Rocky Hill
__ U Union, Ashford, Mansfield, Chaplin, Hampton, Windham, Scotland, Lebanon
__ V Cromwell, Portland, Middletown, Middlefield, Durham, East Hampton, Haddam, East Haddam,
Chester, Essex, Killingworth, Deep River, Westbrook, Old Saybrook
__ W Lyme, Old Lyme, East Lyme, Salem, Montville, Waterford, New London, Ledyard, Groton,
Stonington, North Stonington
__ X Bozrah, Franklin, Norwich, Sprague, Lisbon, Preston, Griswold, Voluntown
__ Y Woodstock, Thompson, Putnam, Pomfret, Eastford, Brooklyn, Canterbury, Plainfield, Sterling,
Killingly
__ Z Glastonbury, Marlborough, Colchester, Hebron, Columbia, Andover, Bolton, Coventry
 PAGE TEN
Harris Jordan E
________________________________________ _______________________ ____
Last Name First Name MI
______________________________________________________________________
Examination Title or Position Title

SECTION 11: TESTING ACCOMMODATIONS FOR EXAMINATIONS

Qualified individuals with a disability may request special testing accommodations under
provisions of the Americans with Disabilities Act (ADA) by contacting DAS Statewide Human
Resources at 860-713-5206 (voice) and at 860-713-7463 (TDD) immediately upon submitting an
application for this examination. Provide your name, exam title and number, a description of
your specific needs and documentation from a health care provider verifying your disability.

SECTION 12: VOLUNTARY

In order to meet State and Federal reporting requirements, we are requesting that you voluntarily
supply the following information. This data will not be considered in the evaluation of your
application.

A. SEX: ___ Female ✔ Male

___

B. RACE/ETHNIC DATA:
__ 1 AMERICAN INDIAN OR ALASKAN NATIVE: Persons having origins in any of the original
peoples of North America, and who maintain cultural identification through tribal affiliation or
community recognition.
__ 2 ASIAN/ PACIFIC ISLANDER: Persons having origins in any of the original peoples of the Far
East, Southeast Asia the Indian Subcontinent or the Pacific Islands. This area includes, for
example, China, Japan, Korea, the Philippine Islands, and Samoa.
✔3
__ BLACK/AFRICAN-AMERICAN (NOT OF HISPANIC ORIGIN): Persons having origins in any
of the black racial groups of Africa.
__ 4 HISPANIC: Persons of Mexican, Puerto Rican, Central or South American or other Spanish
culture or origin, regardless of race.
__ 5 WHITE (NOT OF HISPANIC ORIGIN): Persons having origins in any of the original peoples of
Europe, North Africa, or the Middle East.

C. PRIMARY SOURCE OF EXAM/JOB INFORMATION:

Where did you learn about this exam or job/position? (Check and complete below.)
www.das.state.ct.us/exam
✔ 1 State of Connecticut Internet site. Website: _______________________________________
__
__ 2 Other Internet Site. Website: __________________________________________________
__ 3 Newspaper, professional journal, radio or TV advertisement.
Please give the name of the publication/station, etc: _________________________________
__ 4 Paper Posting
__ 5 Direct e-mail or paper mailing.
__ 6 Career fair. Event/Location: ____________________________________________________
__ 7 Other. Please specify: ________________________________________________________