State of Tennessee Employment Application 2

STATE OF TENNESSEE
EMPLOYMENT APPLICATION
USE BLACK INK ONLY TO COMPLETE THIS APPLICATION FORM. PLEASE 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 titles for which you are applying and the corresponding county preference.
Do not use abbreviations as this may result in your application being processed for the incorrect title.
Job Title/Classification
County Preference
PLEASE COMPLETE ALL INFORMATION REQUESTED BELOW. PRINT CAREFULLY TO INSURE THAT
YOUR INFORMATION IS ACCURATELY RECORDED INTO YOUR APPLICANT RECORD.
LAST NAME
FIRST NAME
MAILING ADDRESS
CITY
AREA CODE
ST
HOME TELEPHONE
AREA CODE
ZIP CODE
ALTERNATE PHONE
EMAIL ADDRESS
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
NO
REQUIRED ANSWER MUST BE RECORDED HERE
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.
Please return completed application to:
Department of Human Resources
Recruiting Management Services Division
505 Deaderick Street, 2nd Floor, James K. Polk Building
Nashville, TN 37243-0635 or fax to (615) 401-7626
STATE OF TENNESSEE
EMPLOYMENT APPLICATION
ATTENTION APPLICANTS:
ATTENTION AGENCIES:
DO NOT INCLUDE THIS PAGE WHEN PROVIDING A COPY OF YOUR
APPLICATION FOR AN EMPLOYMENT INTERVIEW.
DO NOT INCLUDE THIS PAGE IF YOU KEEP A COPY OF THIS
APPLICATION FOR YOUR RECORDS.
VETERANS PREFERENCE:
Tennessee veteran’s preference is extended to applicants listed on the
appointment or promotional list. To be eligible for veterans preference, you must have received an honorable
discharge from the army, navy, air force, marine corps or coast guard or any member of the reserve components,
as defined in 10 U.S.C. § 10101, who performs active federal service in the armed forces of the United States.
Proof of dates of military service, honorable discharge, disability, death, and residence are required and must be
provided to the Department of Human Resources in order to receive Veterans Preference. A spouse or surviving
spouse of a veteran is eligible if these conditions are met: as a result of such military services, the veteran
suffered a one hundred (100%) percent service-connected disability or is permanently and totally disabled; or the
veteran died in the line of duty during such military service; and the surviving spouse has not remarried since the
death of the veteran.
TO CLAIM VETERANS PREFERENCE, CHECK THE APPROPRIATE BOX BELOW AND SUBMIT
PROOF AS INDICATED IN THE TABLE.
Proof will be submitted under separate cover
Proof is attached
Proof has previously been submitted to Applicant Services
Date of Entry in Military Service
Month
Day
Year
Branch of Service:_____________________
Date of Separation from Active Service
Month
Day
Year
Rank at Discharge:____________________
SPECIAL QUALIFICATION INFORMATION: Employment consideration for some jobs 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.
To be considered for jobs requiring U.S. citizenship, please answer: Are you a U.S. citizen?_____________
To be considered for positions requiring a minimum age: Are you at least 21 years of age?:____________
***OPTIONAL INFORMATION***
The following information is for Equal Employment Opportunity/Affirmative Action purposes only. To assist the State of TN
in its commitment to equal employment opportunity, applicants are asked to voluntarily provide the following information.
The State of TN 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 an applicant’s failure or refusal to provide this information will
not affect an applicant’s employment opportunities. Data will be held confidential and only used in accordance with
applicable federal law. Refusal to provide information will not subject the applicant to any adverse treatment.
RACE:
_____White
_____Asian or Pacific Islander
_____Other
SEX:
_____Male
_____Black
_____Native American Indian
_____Hispanic
_____Alaskan Native
_____Female
Please return completed application to:
Department of Human Resources
Recruiting Management Services Division
505 Deaderick Street, 2nd Floor, James K. Polk Building
Nashville, TN 37243-0635 or fax to (615) 401-7626
STATE OF TENNESSEE
EMPLOYMENT APPLICATION
EDUCATIONAL BACKGROUND
Please indicate the highest level of primary or secondary education completed.
1
2
3
4
5
6
7
8
9
10
11
GED
High School
Cert. of
Diploma Completion
POSTSECONDARY EDUCATION – Please list schools attended after high school. This includes
any colleges, universities or vocational schools.
Name and City/State of
School
Dates Attended
To
From
# of hours
Completed
Did you
Graduate
Yes No
Date of
Graduation
Major
Type of
Degree
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
ISSUE
DATE
EXPIRATION
DATE
STATE/ISSUING
AGENCY
EXPERIENCE BACKGROUND
INSTRUCTIONS: To complete your work history, use the job blocks provided below and on the following
pages, beginning with your present or most recent job. 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. You may submit an employment resume to supplement
your application.
Job Title______________________________________
Hours per week_____________
Employment dates____________/_____________
Starting Salary____________
Ending Salary____________
Employer Name:_____________________________________________________________________________
Employer Address:__________________________________________________Phone___________________
Name of Supervisor:________________________________ # of employees you supervised_______________
Reason for leaving:___________________________________________________________________________
Duties:______________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please return completed application to:
Department of Human Resources
Recruiting Management Services Division
505 Deaderick Street, 2nd Floor, James K. Polk Building
Nashville, TN 37243-0635 or fax to (615) 401-7626
STATE OF TENNESSEE
EMPLOYMENT APPLICATION
Job Title______________________________________
Hours per week_____________
Employment dates____________/_____________
Starting Salary____________
Ending Salary____________
Employer Name:_____________________________________________________________________________
Employer Address:__________________________________________________Phone___________________
Name of Supervisor:________________________________ # of employees you supervised_______________
Reason for leaving:___________________________________________________________________________
Duties:______________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Job Title______________________________________
Hours per week_____________
Employment dates____________/_____________
Starting Salary____________
Ending Salary____________
Employer Name:_____________________________________________________________________________
Employer Address:__________________________________________________Phone___________________
Name of Supervisor:________________________________ # of employees you supervised_______________
Reason for leaving:___________________________________________________________________________
Duties:______________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Job Title______________________________________
Hours per week_____________
Employment dates____________/_____________
Starting Salary____________
Ending Salary____________
Employer Name:_____________________________________________________________________________
Employer Address:__________________________________________________Phone___________________
Name of Supervisor:________________________________ # of employees you supervised_______________
Reason for leaving:___________________________________________________________________________
Duties:______________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please return completed application to:
Department of Human Resources
Recruiting Management Services Division
505 Deaderick Street, 2nd Floor, James K. Polk Building
Nashville, TN 37243-0635 or fax to (615) 401-7626
STATE OF TENNESSEE
EMPLOYMENT APPLICATION
REFERENCES: Please provide complete information for your references below. Please make sure your
reference information is current with each new application you submit.
NAME
ADDRESS
CITY-STATE
PHONE
Equal Opportunity Employer:
The State of Tennessee prohibits discrimination against applicants and employees on the basis of
race, color, sex, religion, national origin, age, disability, veteran’s status, or any other category
protected under federal or state law in recruitment, hiring, discharge, promotion, or any other
aspect of employment.
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 consideration. 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,
and/or organization (including law enforcement agencies) to provide all information that may be
sought in connection with this application.
Signature of Applicant______________________________________________Date_______________
Please return completed application to:
Department of Human Resources
Recruiting Management Services Division
505 Deaderick Street, 2nd Floor, James K. Polk Building
Nashville, TN 37243-0635 or fax to (615) 401-7626