The State of Oklahoma Employment Application

The State of Oklahoma Employment Application
50046
DO NOT STAPLE
Office of Personnel Management
Jim Thorpe Memorial Office Building, B-22
2101 North Lincoln Boulevard
Oklahoma City, OK 73105
Phone: 405-521-2171
Fax:
405-521-6308
Last Name
First Name
MI
Thank you for your interest in employment with the State of Oklahoma. The attached application is part of the
selection process. Before completing the application, read these instructions and the Job Bulletin to ensure you
submit all of the information necessary to evaluate your application.
Your application and all additional materials will be scanned. Complete all forms in black or blue ink, using
capital letters, and stay within the boxes provided. See example below:
Once your application is scanned, the boxes will disappear and the application will be reformatted for on-line
review.
If you have concerns about the appearance of your application, or would like to copy your application for other
jobs, we encourage you to apply on-line at : www.opm.ok.gov/jobs
You are required to provide the following tracking information on the application: The first three letters of your
last name at birth, the month and day of your birth and the last four digits of your social security number. Your
application package will not be processed without this information.
Any additional materials (e.g. Supplemental Questionnaire, transcripts, etc.) which are sent separately require
a completed Additional Document Cover Sheet, which is included in this packet.
If you are not applying on line, you must complete a separate scannable application for each job for which you
apply. Online applicants may copy application following online directions. Do not submit a resume in place of
completing any part of the application.
Applications and attachments will not be returned or photocopied for you.
If you are disabled and need accommodation in the testing process, please contact the Office of Personnel
Management as soon as you receive your test invitation.
Please notify the Office of Personnel Management if you change your address (including your e-mail address),
phone number, or name.
Page 1
LIST OF OKLAHOMA COUNTIES
50046
01 Adair
02 Alfalfa
03 Atoka
04 Beaver
05 Beckham
06 Blaine
07 Bryan
08 Caddo
09 Canadian
10 Carter
11 Cherokee
12 Choctaw
13 Cimarron
14 Cleveland
15 Coal
16 Comanche
17 Cotton
18 Craig
19 Creek
20 Custer
21 Delaware
22 Dewey
23 Ellis
24 Garfield
25 Garvin
26 Grady
27 Grant
28 Greer
29 Harmon
30 Harper
31 Haskell
32 Hughes
33 Jackson
34 Jefferson
35 Johnston
36 Kay
37 Kingfisher
38 Kiowa
39 Latimer
40 LeFlore
41 Lincoln
42 Logan
43 Love
44 McClain
45 McCurtain
46 McIntosh
47 Major
48 Marshall
49 Mayes
65 Roger Mills
50 Murray
66 Rogers
51 Muskogee 67 Seminole
52 Noble
68 Sequoyah
53 Nowata
69 Stephens
54 Okfuskee
70 Texas
55 Oklahoma 71 Tillman
56 Okmulgee 72 Tulsa
57 Osage
73 Wagoner
58 Ottawa
74 Washington
59 Pawnee
75 Washita
60 Payne
76 Woods
61 Pittsburg
77 Woodward
62 Pontotoc
63 Pottawatomie
64 Pushmataha
There are 2 places on the Scannable Application that use a 2 digit number to represent a County. Use the list
above to fill in the correct response for the County.
THE FOLLOWING IS AN EXAMPLE ONLY:
1. In the Example (from page 4) Below we have Entered 02 (Alfalfa)
2. In the Example (from page 5) Below we have Entered 02 (Alfalfa) and 76 (Woods)
Page 2
Fill circles completely for your choices. If a mark lies entirely outside of the circle, it will not
be counted. Example
My choice
A choice not selected
50046
Position applied for:
Voluntary Applicant Survey
The information requested will be used to assist state agencies in complying with state and federal record keeping and reporting
requirements. It may be made available to employing agencies when they exercise state laws authorizing affirmative action in hiring.
Please provide accurate information. Your cooperation is important and appreciated. State law requires any person who lists
American Indian as his/her race or ethnic group to verify tribal affiliation by providing a certificate of degree of Indian Blood from the
U.S. Department of Interior, Bureau of Indian Affairs, or by providing the name and address of tribal officials who can verify tribal
affiliation. Do NOT turn the verification in with this employment application.
This information will be kept separate and confidential. It will not be used in any way to make employment decisions.
Please answer below based upon how you identify yourself. We understand that it may be difficult to choose a single ethnic identity
if you have a multicultural heritage. Nevertheless, to comply with legal guidelines, we would like you to choose only one.
Ethnicity:
White (not of Hispanic origin):
All persons not classified into one of four specific ethnic minority categories that follow.
Black (not of Hispanic origin):
All persons having origins in any of the Black racial groups.
Hispanic
All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish
culture or origin, regardless of race.
Asian or Pacific Islander
All persons having origins in any of the original peoples of the Far East, Southeast Asia, the
Pacific Islands, or the Philippine Islands. For example: China, Japan, Korea, Samoa, the
Indian Subcontinent, the Philippines and the Middle East.
American Indian or Alaskan Native
All persons having origins in any of the original peoples of North America.
Unknown/Not Willing to State
Gender:
Male
Female
I first learned about this job opportunity through (select only one):
Job Interest Form
OPM staff suggested that I apply
Other State Employee
Placement Officer at My School
Professional Publication
Newspaper
Office of Personnel Management Web Page
Other Web Page
Other
Describe Other:
Page 3
Office of Personnel Management
Jim Thorpe Memorial Office Building, B-22
2101 North Lincoln Boulevard
Oklahoma City, OK 73105
Phone: 405-521-2171 Fax: 405-521-6308
50046
APPLICATION FOR EMPLOYMENT
Disclosure of your Social
Security Number is voluntary.
It will be used for identification
purposes only to ensure that
proper records are maintained.
Recruitment Number
-
Applicant Identification Number
-
First 3 letters of
Last Name at Birth
Last 4 digits of Social
Security Number
Month of Birth
Day of Birth
Social Security Number
-
-
Title of Position
Last Name
First Name
MI
Mailing Address (please include apt.#)
City
State
-
Zip
Country
County
Use the County List (on page 2) to enter your County of residence:
Day Phone Number
Ext.
-
-
OK to leave msg?
Yes
No
Yes
No
Night Phone Number
-
-
Alternate Phone Number
-
Yes
OK to leave msg?
No
Ext.
-
OK to leave msg?
E-Mail Address (Optional) provide only if we may contact you primarily via e-mail. Please write clearly so that we can tell
the difference between letters and numbers, e.g., "O" and "0" (zero); "I" or "L" and 1 (one)
For Office of Personnel Management Use Only
Date Received
/
Received By
Number of Pages (not blank)
/
Page 4
50046
Counties in which I will consider employment (up to 5 counties): Make sure to include your resident
county.
Use the County List (on page 2) to enter your choices.
Location 1
Location 2
Location 3
Location 4
Location 5
Are you a current State of Oklahoma employee?
Yes
Job Title
No If "Yes" complete the following:
Agency
Bilingual Ability. Please list languages (other than English) in which you are fluent.
Are you claiming Verteran's Preference?
Speak Fluently
Speak/Read/Write
N/A
Speak Fluently
Speak/Read/Write
N/A
Yes
No
If "Yes" complete the following:
Has the veteran been a resident of Oklahoma for at least one year?
Yes
No
Indicate the type of preference you are claiming and submitting documentation for:
5 pts. preference
10 pts. preference
10 pts. preference and top of list
5 pts. preference for spouse of veteran certified as unemployable
5 pts. preference for unremarried surviving spouse
No Points
To claim Veteran's preference completed forms and required documents must be submitted to OPM
by mail at Jim Thorpe Memorial Office Building, Room B-22, 2101 N. Lincoln Blvd., Oklahoma City,
OK 73105 or by fax at (405) 521-6308.
OPTIONAL:
This information may be used for database searches.
Major Subject of Education
Major Area of Employment Experience
Years of Employment in Major Area
Page 5
50046
Education, Licenses and Training: You may wish to review the job requirements section of the Bulletin. Please
read the Minimum Qualifications for this job carefully. If specific education, certification, licensure or training is required,
that information must be provided below or you may be disqualified from further consideration. Attach additional sheets
if you need more space to describe licenses or schooling.
Do you have any current occupational and professional licenses and certificates?:
Issuing Agency
Title
Date Issued
Expiration Date
Title
Date Issued
Name and Address of College, University,
Vocational School or Institute
No
Yes
ID#
Issuing Agency
Expiration Date
Major/Minor Course of Study
ID#
Dates of
Attendance
Certificate/Degree
Obtained or expected
Associates
Masters
Completed/
# units earned
Yes
Bachelors
Ph.D.
Other
Certificate
Associates
Masters
Yes
Bachelors
Ph.D.
No
Other
Certificate
Associates
Masters
Yes
Bachelors
Ph.D.
No
Other
Certificate
No
Use this space to list other courses, training or education that you believe is relevant to the job you are
applying for. You may also use this space to explain information you provided above.
Page 6
Position Applied for:_____________________________ Applicant Name ____________________________________
EMPLOYMENT HISTORY
YOU MUST COMPLETE THIS SECTION. Begin with your most recent experience, starting with your current job. Be sure to include
all experience, regardless of dates, which demonstrates that you meet the minimum requirements as shown on the announcement for the
position. Attach additional sheets if you need more space to describe duties or list former employers. Describe your duties as completely
as possible. Incomplete information may cause a delay in processing your application. If you supervise(d) employees, include the number
of employees you supervise(d). If you held more than one position with the same employer, list each separately.
Employer: ___________________________________________________ Dates Employed:
From____/____/____ To___/____/____
Mo.
Day
Year
Mo.
Day
Year
(If you do not know the exact date, enter 01 for the "Day" portion of the date.)
Address: _____________________________________________________________________________________________________
Street Name
City
State
Zip
Hours Worked Per Week: _______________ Number of employees you supervised: __________
Your Job Title: _________________________________________ Your Supervisor’s Name: ___________________________________
Duties Performed: ______________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Reason For Leaving: ____________________________________________________________________________________________
Last Salary: $ _______________________Per ______________ Equipment Used:_________________________________________________________
Employer: ___________________________________________________ Dates Employed:
From____/____/____ To___/____/____
Mo.
Day
Year
Mo.
Day
Year
(If you do not know the exact date, enter 01 for the "Day" portion of the date.)
Address: _____________________________________________________________________________________________________
Street Name
City
State
Zip
Hours Worked Per Week: _______________ Number of employees you supervised: __________
Your Job Title: _________________________________________ Your Supervisor’s Name: ___________________________________
Duties Performed: ______________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Reason For Leaving: ____________________________________________________________________________________________
Last Salary: $ _______________________Per ______________ Equipment Used:_________________________________________________________
21920
DOCUMENT COVER SHEET
If you are sending additional documents with your application now or separately at a later time, you
are required to use this Document Cover Sheet for each set of documents you send. Please make a
copy of this form if necessary.
Additional documents will not be processed unless you provide the following information.
Recruitment Number
-
-
Title of Position
First three letters of last name at birth
Last four digits of SSN
Month of Birth
Day of Birth
Last Name (Cut off if longer than space provided)
MI
First Name
Fill circle completely for each item you are sending.
Supplemental Questionnaire
Additional Work History Sheets
License
Transcript
Endorsement of Faith
Veteren's Administration Letter
Veteran's Marriage License
Veteran's Death Certificate
Veteran's Preference DD214
Other
Place cover sheet(s) on top of materials and mail or fax to:
Office of Personnel Management
Jim Thorpe Memorial Office Building, B-22
2101 North Lincoln Boulevard
Oklahoma City, OK 73105
Fax: 405-521-6308
For Office of Personnel Management Use Only
Date Received
/
/
Received By
Number of Pages (non-blank)