State of Tennessee Employment Application 1

Return completed application to:
STATE OF TENNESSEE
EMPLOYMENT APPLICATION
Department of Human Resources
Applicant Services Division
505 Deaderick Street
nd
2 Floor, James K. Polk Building
Nashville, Tennessee 37243-0635
or fax to: (615) 401-7626
USE BLACK INK ONLY TO COMPLETE THIS APPLICATION FORM. DO NOT WRITE IN SHADED AREAS. COMPLETE ALL
REQUIRED FIELDS OR YOUR APPLICATION WILL BE RETURNED TO YOU.
Please record your Social Security Number below.
List the specific State of Tennessee job classification titles for which you are applying. Do not
use abbreviations as this may result in your application being processed for the incorrect title.
APP.
CODE
CLASS
CODE
REJ.
CODE
1.
2.
3.
4.
5.
PLEASE COMPLETE ALL INFORMATION REQUESTED BELOW.
ACCURATELY RECORDED INTO YOUR APPLICANT RECORD.
PRINT CAREFULLY TO INSURE THAT YOUR INFORMATION IS
LAST NAME
FIRST NAME
MI
MAILING ADDRESS
CITY
AREA CODE
STATE
HOME TELEPHONE
AREA CODE
ZIP CODE
BUSINESS TELEPHONE
Have you ever been convicted, forfeited bond, or are you currently on probation for any felony (or any equal offense under military law)?
(A felony is defined as an offense punishable by imprisonment for a term of one year or greater.)
YES
Required answer must be recorded here 
NO
If yes, give details on a separate sheet of paper for each felony offense. Include (1) date, (2) charge, (3) place, (4) court, and (5) action taken. You must disclose
any felony conviction involving a sentence or suspended sentence. You may omit: (1) any offense committed before your 18th birthday which was finally adjudicated
in a juvenile court; (2) any conviction which has been expunged under federal or state law. A conviction will not necessarily disqualify you from the job for which
you are applying. A conviction will be judged on its own merits with respect to time, circumstances, and seriousness.
COUNTY PREFERENCES: Record the two-digit code(s) for each county in which you are willing to work (See Information and Instructions Side B for list of
county codes). You may list up to five counties or indicate “99” for statewide. At least one county must be listed.
County Preferences 
LEGAL RESIDENT COUNTY: In the box below, you must record your legal resident county. Non-state residents must indicate “00” as their legal resident county.
Legal Resident County 
(must be recorded
here)
Please note: Your legal county is the county in which you reside and to which you definitely intend to return
even though you may be temporarily absent. Your application cannot be processed without this information.
--PLEASE READ--
The State of Tennessee Employment Application Form is used by the State to establish an applicant’s qualifications and employment preferences. This
application does not constitute a contract between the State and an applicant.
******************************
The State of Tennessee is committed to the principles of equal opportunity, equal access, and affirmative action. The State of Tennessee does not
discriminate against applicants or employees on the basis of race, color, religion, creed, age (over 40), national origin, sex, pregnancy, disability, veteran’s
status or any other classification protected by federal or state law.
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PR-0007 (Rev. 04/05)
***ATTENTION APPLICANTS: DO NOT INCLUDE THIS PAGE WHEN PROVIDING A COPY OF YOUR APPLICATION FOR AN EMPLOYMENT INTERVIEW***
ATTENTION APPOINTING AUTHORITIES: DO NOT INCLUDE THIS PAGE IF YOU KEEP A COPY OF THIS APPLICATION FOR YOUR FILE S***
--Do not write in shaded area - office use only--
TESTING: If you are willing to take any necessary examinations, please indicate your testing location preference from the choices below.
MARK ONE
___ 06 Cleveland
___ 19 Nashville
___ 28 Pulaski
___ 47 Knoxville
___ 57 Jackson
___ 67 Livingston
___ 79 Memphis
___ 82 Kingsport
If you would like information on testing accommodations for persons with disabilities, please call (615) 741-0441 or TDD (615) 741-6276. See information under the
heading “Testing Information” on Side A of Information and Instructions for further information about the employment testing process.
VETERANS INFORMATION: Tennessee veterans preference points are only added to passing examination scores on Career Service appointment registers. To
receive veterans preference points, you must be a present or former member of the United States Armed Forces, have served on active duty during the service
eligibility periods listed below (unless otherwise noted), have received an honorable discharge, and be a legal resident of the State of Tennessee (i.e., have resided in
the State of Tennessee for the past two-year period or possess a Tennessee voter registration card). Veterans meeting these conditions will have five (5) points added
to their passing examination scores. For veterans with a ten percent (10%) or greater service-connected disability, ten (10) points will be added to their passing
examination scores. Ten (10) points will be added to the passing examination scores of the spouse or unremarried spouse of a one hundred percent (100%) serviceconnected disabled veteran or the unremarried spouse of a veteran killed on active duty during the eligibility periods listed below. Five (5) points will be added to the
passing examination scores of the spouse or unremarried spouse of a one hundred percent (100%) service-connected disabled veteran or unremarried spouse of a
veteran killed on active duty during any other time period.
Service Eligibility Dates: W.W.II (12-7-41 to 12-31-46); Korean Campaign (6-27-50 to 1-31-55); Vietnam Conflict (2-28-61 to 5-7-75); Lebanon, Grenada or
Panama Expeditions (ONLY IF AWARDED THE ARMED FORCES EXPEDITIONARY MEDAL); and Operation Desert Shield/Storm (8-2-90 to end date not yet
established).
TO CLAIM VETERANS PREFERENCE, CHECK THE APPROPRIATE BOX BELOW AND SUBMIT PROOF AS INDICATED IN THE TABLE.
Proof will be submitted under separate cover
Date of Entry in Military Service
Month
Day
Proof is Attached
Proof has previously been submitted to Applicant Services
Date of Separation from Active Service
Year
Month
Day
Year
Rank at Time of Discharge
Branch of Service
VETERAN STATUS:
REQUIRED DOCUMENTS:
DOCUMENT TYPES:
Veteran
submit document 1 only
1. Discharge (DD Form 214) showing entry and honorable discharge date from active military service.
10% Disabled Veteran
submit documents 1 and 2
2. *Statement from Veterans Administration showing veteran's 10% service-connected disability.
Spouse-100% Disabled Veteran
submit documents 1 and 3
3. *Statement from Veterans Administration showing veteran's 100% service-connected disability.
Spouse-Veteran killed on active duty
submit documents 1 and 4
4. Statement from Veterans Administration showing veteran was killed while on active duty.
*Statement must have been issued from Veterans Administration within last six months .
SPECIAL QUALIFICATION INFORMATION: Employment consideration for some jobs (e.g., Correctional Officer, Trooper, other jobs in law enforcement) is
limited to U.S. citizens and/or to individuals who meet minimum age requirements. If you are applying for a job for which U.S. citizenship or minimum age
requirements are applicable, please provide the information in this block. (Note: To obtain information about special qualifications requirements for a particular job,
please visit the Department of Human Resources Job Search website at http://tn.gov/dohr/employment/career.html.
To be considered for jobs requiring U.S. citizenship, please answer:
Are you a U.S. citizen?
YES
NO
To be considered for jobs requiring a minimum age of 18, please answer:
Are you at least 18 years of age?
YES
NO
To be considered for jobs requiring a minimum age of 21, please answer:
Are you at least 21 years of age?
YES
NO
***OPTIONAL INFORMATION***
t
DEMOGRAPHIC INFORMATION: The following information is for Equal Employment Opportunity/Affirmative Action purposes only. To assist the State
of Tennessee in its commitment to equal employment opportunity, applicants are asked to provide voluntarily the following information. The State of Tennessee is
authorized under federal law to retain this information for research and statistical reasons. This information will not be used in an employment decision and refusal to
provide this information will not affect an applicant’s employment opportunities. Information requested is to be completed on a voluntary basis. Data will be held
confidential and only used in accordance with applicable federal law.
RACE
SEX
A.
White
B.
Black
C.
Hispanic
E.
Native American Indian
F.
Alaskan Native
G.
Other
A.
Male
B.
D.
Asian or Pacific Islander
Female
.
****ATTENTION APPLICANTS: DO NOT INCLUDE THIS PAGE WHEN PROVIDING A COPY OF YOUR APPLICATION FOR AN EMPLOYMENT INTERVIEW***
**ATTENTION APPOINTING AUTHORITIES: DO NOT INCLUDE THIS PAGE IF YOU KEEP A COPY OF THIS APPLICATION FOR YOUR FILES***
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Social Security Number
Last Name
First Name
EDUCATIONAL BACKGROUND
You should provide all information requested in this section. You may omit the Educational Background section only if you have filed a full and complete
application since March, 1999, and your education information has not changed since that time. This applies to all applicants including current State Employees.
PLEASE NOTE: You should complete “LICENSES” and “REFERENCES” with each new application you submit. Signature is required with each application.
Primary/Secondary Education - Please indicate the highest level of primary or secondary education completed.
__________________
1
2
3
4
5
6
7
8
9
10
11
certif. of
GED
completion certif.
high school
diploma
date
completed
Postsecondary Education - Please list schools attended after high school. This includes any colleges, universities, or vocational schools attended. When
indicating hours completed, you must convert semester hours to quarter hours. Just multiply semester hours by 1.5 to convert to quarter hours. Indicate clock
hours for vocational school training.
Name and city/state location of school
Dates attended Total # of quarter
Did you
FROM
TO
or clock hours
Graduate?
MO/YR MO/YR
completed
YES NO
Type of degree or
certificate and date
(MO/YR) received
Major field of
study or area of
concentration
To ensure that you receive the maximum score possible in an evaluation of your training and experience, it is strongly recommended that you submit a copy of your
college transcript with your application. Regardless of whether or not you are submitting a transcript, please indicate the number of quarter hours received in the
subjects listed below. A transcript of all course work may be required at the time of employment. For education received from a non-United States college or
university, please attach a copy of credential evaluation from an accredited United States school or other acceptable evaluation service.
(To convert semester hours to quarter hours, multiply by 1.5.)
Accounting
Political
Science
Environmental
Engineering
Psychology
Agribusiness
Human
Anatomy
Mental Health
Chemistry
Computer
Science
Drafting
Sociology
Agriculture
Human
Nutrition
Non State
CEU* credit
Biology
Mathematics
Education
Environmental
Health/Physics
Archaeology
Industrial
Arts
Nursing
Microbiology
Statistics
Geology
Child/Family
Studies
Law/Legal
Assistance
Recreation/
Rec. Therapy
Business/
Economics
Civil
Engineering
Special
Education
Computer Sci.
Counseling
Library
Science
Criminal
Justice
Marketing
Rehabilitation
Studies
* CEU credits earned by State employees through state sponsored training will be automatically recorded in their applicant records. To obtain credit for non-state
sponsored CEUs or vocational technical school training, an official transcript must be attached.
LICENSES: Please list each license, certificate, or other authorization to practice a trade or profession. Teachers must specify subject area and type of
certification. Please make sure licensure information is current with each new application you submit.
TYPE OF CERTIFICATION
AREA OF
ENDORSEMENT
LICENSE NO.
ORIGINAL LICENSE
ISSUE DATE
CURRENT LICENSE
EXPIRATION DATE
STATE OR AGENCY
ISSUING LICENSE
REFERENCES: Please provide complete information for your references below. Please make sure your reference information is current with each new
application you submit.
NAME
STREET ADDRESS
CITY - STATE
TELEPHONE
SIGNATURE: Under penalty of perjury, I certify that the information I am providing in this application is correct and complete to the best of my knowledge. I am
aware that should investigation show any falsification or material misrepresentation, I will not be considered for employment, or if employed, I will be dismissed and
disqualified from future examinations. I hereby authorize the State of Tennessee to make all necessary investigations concerning me or my actions and to receive and
make available to all state agencies my academic records or other materials pertinent to my qualifications. I further authorize and request each former employer,
educational institution, or organization (including law enforcement agencies) to provide all information that may be sought in connection with this application.
SIGNATURE OF APPLICANT
DATE
***Signature is required. Unsigned applications will be returned to the applicant***
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EXPERIENCE BACKGROUND
***Important - Please Read***
Instructions: You should provide your complete work history in the experience background section on the following pages unless you have
submitted a full and complete application since March, 1999. This applies to all applicants, including current State employees. In
providing your complete work history information, you may use copies of pages from previous applications to construct one complete and up-todate application. If you have submitted a full application since March, 1999, you may omit your prior work experience, except for the
experience you have gained since the time of your last application. Even if you have continued in the same job, that job should be listed in job
block A to show that you’ve continued working in the same position.
To complete your work history, use the job blocks provided below and on the following pages, beginning with your present or most recent job in
job block A. If necessary, you may attach additional sheets to provide your complete work history in the format shown below. It is important
that you accurately describe the major responsibilities associated with each job you have held, along with all other requested information for each
job. Incomplete information may lower your application rating. If you moved to a different position within the same organization and your
major duties changed, you must list each position as a separate job. For military experience, it is important that you include the dates and pay
grade for each position held. Unpaid, volunteer or part-time work experience may also be included with your work experience history. You may
submit an employment resume to supplement your application; however, you must describe your major job responsibilities in the format
below to ensure accurate scoring of your application.
***If you have not reviewed the information above, please do so now to be sure you complete this section correctly.***
JOB A
TITLE OR RANK OF POSITION :
EMPLOYED FROM
TO
MO.
YR.
REASON FOR LEAVING :
MO.
YR.
AVERAGE # OF HRS. WORKED PER WEEK:
STARTING ANNUAL SALARY :
$
TYPE OF BUSINESS :
EMPLOYER NAME :
LAST ANNUAL SALARY :
$
TELEPHONE:
EMPLOYER ADDRESS :
STREET
CITY
AVERAGE # OF EMPLOYEES YOU SUPERVISED :
STATE
ZIP CODE
NAME OF YOUR IMMEDIATE SUPERVISOR :
Describe your major duties /responsibilities and show approximate percent of time spent on each. Do not exceed a total of 100%.
% TIME
DUTIES/RESPONSIBILITIES
100 %
JOB B
TITLE OR RANK OF POSITION :
EMPLOYED FROM
TO
MO.
YR.
REASON FOR LEAVING :
MO.
YR.
AVERAGE # OF HRS. WORKED PER WEEK:
EMPLOYER NAME :
STARTING ANNUAL SALARY :
$
TYPE OF BUSINESS :
LAST ANNUAL SALARY :
$
TELEPHONE:
EMPLOYER ADDRESS :
STREET
AVERAGE # OF EMPLOYEES YOU SUPERVISED :
CITY
STATE
ZIP CODE
NAME OF YOUR IMMEDIATE SUPERVISOR :
Describe your major duties /responsibilities and show approximate percent of time spent on each. Do not exceed a total of 100%.
% TIME
DUTIES/RESPONSIBILITIES
100 %
USING THE FORMAT ABOVE, ATTACH ADDITIONAL SHEETS IF NECESSARY TO COMPLETE YOUR EMPLOYMENT HISTORY.
4
JOB C
TITLE OR RANK OF POSITION :
EMPLOYED FROM
TO
MO.
YR.
REASON FOR LEAVING :
MO.
YR.
AVERAGE # OF HRS. WORKED PER WEEK:
STARTING ANNUAL SALARY :
$
TYPE OF BUSINESS :
EMPLOYER NAME :
LAST ANNUAL SALARY :
$
TELEPHONE:
EMPLOYER ADDRESS :
STREET
CITY
AVERAGE # OF EMPLOYEES YOU SUPERVISED :
STATE
ZIP CODE
NAME OF YOUR IMMEDIATE SUPERVISOR :
Describe your major duties /responsibilities and show approximate percent of time spent on each. Do not exceed a total of 100%.
% TIME
DUTIES/RESPONSIBILITIES
100 %
JOB D
TITLE OR RANK OF POSITION :
EMPLOYED FROM
TO
MO.
YR.
REASON FOR LEAVING :
MO.
YR.
AVERAGE # OF HRS. WORKED PER WEEK:
STARTING ANNUAL SALARY :
$
TYPE OF BUSINESS :
EMPLOYER NAME :
LAST ANNUAL SALARY :
$
TELEPHONE:
EMPLOYER ADDRESS :
STREET
CITY
AVERAGE # OF EMPLOYEES YOU SUPERVISED :
STATE
ZIP CODE
NAME OF YOUR IMMEDIATE SUPERVISOR :
Describe your major duties /responsibilities and show approximate percent of time spent on each. Do not exceed a total of 100%.
% TIME
DUTIES/RESPONSIBILITIES
100 %
JOB E
TITLE OR RANK OF POSITION :
EMPLOYED FROM
TO
MO.
YR.
REASON FOR LEAVING :
MO.
YR.
AVERAGE # OF HRS. WORKED PER WEEK:
EMPLOYER NAME :
STARTING ANNUAL SALARY :
$
TYPE OF BUSINESS :
LAST ANNUAL SALARY :
$
TELEPHONE:
EMPLOYER ADDRESS :
STREET
AVERAGE # OF EMPLOYEES YOU SUPERVISED :
CITY
STATE
ZIP CODE
NAME OF YOUR IMMEDIATE SUPERVISOR :
Describe your major duties /responsibilities and show approximate percent of time spent on each. Do not exceed a total of 100%.
% TIME
DUTIES/RESPONSIBILITIES
100 %
USING THE FORMAT ABOVE, ATTACH ADDITIONAL SHEETS IF NECESSARY TO COMPLETE YOUR EMPLOYMENT HISTORY.
5
JOB F
TITLE OR RANK OF POSITION :
EMPLOYED FROM
TO
MO.
YR.
REASON FOR LEAVING :
MO.
YR.
AVERAGE # OF HRS. WORKED PER WEEK:
STARTING ANNUAL SALARY :
$
TYPE OF BUSINESS :
EMPLOYER NAME :
LAST ANNUAL SALARY :
$
TELEPHONE:
EMPLOYER ADDRESS :
STREET
CITY
AVERAGE # OF EMPLOYEES YOU SUPERVISED :
STATE
ZIP CODE
NAME OF YOUR IMMEDIATE SUPERVISOR :
Describe your major duties /responsibilities and show approximate percent of time spent on each. Do not exceed a total of 100%.
% TIME
DUTIES/RESPONSIBILITIES
100 %
JOB G
TITLE OR RANK OF POSITION :
EMPLOYED FROM
TO
MO.
YR.
REASON FOR LEAVING :
MO.
YR.
AVERAGE # OF HRS. WORKED PER WEEK:
STARTING ANNUAL SALARY :
$
TYPE OF BUSINESS :
EMPLOYER NAME :
LAST ANNUAL SALARY :
$
TELEPHONE:
EMPLOYER ADDRESS :
STREET
CITY
AVERAGE # OF EMPLOYEES YOU SUPERVISED :
STATE
ZIP CODE
NAME OF YOUR IMMEDIATE SUPERVISOR :
Describe your major duties /responsibilities and show approximate percent of time spent on each. Do not exceed a total of 100%.
% TIME
DUTIES/RESPONSIBILITIES
100 %
JOB H
TITLE OR RANK OF POSITION :
EMPLOYED FROM
TO
MO.
YR.
REASON FOR LEAVING :
MO.
YR.
AVERAGE # OF HRS. WORKED PER WEEK:
EMPLOYER NAME :
STARTING ANNUAL SALARY :
$
TYPE OF BUSINESS :
LAST ANNUAL SALARY :
$
TELEPHONE:
EMPLOYER ADDRESS :
STREET
AVERAGE # OF EMPLOYEES YOU SUPERVISED :
CITY
STATE
ZIP CODE
NAME OF YOUR IMMEDIATE SUPERVISOR :
Describe your major duties /responsibilities and show approximate percent of time spent on each. Do not exceed a total of 100%.
% TIME
DUTIES/RESPONSIBILITIES
100 %
USING THE FORMAT ABOVE, ATTACH ADDITIONAL SHEETS IF NECESSARY TO COMPLETE YOUR EMPLOYMENT HISTORY.
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