Connecticut > Statewide > Administrative
Employment Application Criminal History Record JD-ES-11A - Connecticut
| Employment Application Criminal History Record Form. This is a Connecticut form and can be used in Administrative Statewide . |
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EMPLOYMENTAPPLICATION STATE OF CONNECTICUT AN EQUALOPPORTUNITY AFFIRMATIVE ACTIONEMPLOYER CRIMINALHISTORYRECORD JUDICIAL BRANCH JD-ES-11ANew9/03P.A.02-136Sec.2 www.jud.state.ct.us Thisapplicationmay be made available in an alternateform INSTRUCTIONS: at upon requestby a qualifiedindividualwitha disabilityunder1. Typeorprintin ink,answerallquestionscompletely. theprovisionsof theAmericanswithDisabilitiesAct.If you2. Return withcompletedEmploymentApplicationform(JD-ES-11)to: needassistance,pleasecontactt he RecruitmentSectionof JudicialBranchHuman ResourceManagement Unit, 61 Woodland St., Hartford,CT06105 theHumanResourceManagementUnitat (860)722-1610.POSITION(S) APPLYINGFOR DATEOF APPLICATION NAMEOFAPPLICANT (Last,first,middle) HOMEPHONE (witharea code) BUSINESS PHONE (witharea code) NAMEAND ADDRESS ADDRESS Haveyou ever been convictedof a criminalo ffenseor an offenseagainstmilitarylaw? ( SEE NOTICEBELOW) (Exclude minor traffic violations or any offense settledin a juvenilecourt or under a youthfuloffender law.)IF YES,GIVEDETAILS (Useadditional sheet if necessary) YES NO DETAILS CONTINUED ON BACK/NEXT PAGE (1) You are not required to disclosethe existenceof any arrest,criminal charge or conviction, the recordsof which have been erased pursuant to C.G.S. 46b-146, 54-76o or 54-142a, (2) criminalrecords subject to erasurepursuant to C.G.S. 46b-146, 54-76o or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a fam ily with service needs,an adjudication as a youthful NOTICE offender, a criminal charge that has been dismissed or nolled, a criminalcharge for whichthe person hasbeen foundnot guiltyor a conviction for which the person received an absolute pardon, and (3)any person whose criminal records have been erased pursuant to C.G.S. 46b-146, 54-76o or 54-142a shall be deemed to have never been arrested within the meaning of the general statuteswithrespect to the proceedings so erased and may so swear under oath. I certify thatthe statementsmadeby me on this applicat ion are COMPLETE and TRUE to the best of my knowledge and belief and are made in goodfaith and I have not withheld pertinent information. I understandthat if I knowinglymakeany misstatement of facts,I am subject to disqualification or dismissaland to suchother penalties as may be prescribed by law or Judicial Branch policies. I also understandthat application andappointment to a temporaryposition is no guarantee ofCERTIFICATION appointment to a permanent position. Read this application and your answers CAREFULLY before signing. SIGNED (Applicant) DATESIGNED MUSTbe completed and returnedwith EmploymentApplication(Form JD-ES-11). <<<<<<<<<********>>>>>>>>>>>>> 2 NAMEOFAPPLICANT (Last,first,middle) DETAILS(Continuedfrompreviouspage): DETAILS (Continued) JD-ES-11A (Page2) Rev.9/03 EQUALOPPORTUNITYEMPLOYER
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