Arizona State Personnel System
DISQUALIFICATION FROM STATE EMPLOYMENT REQUEST FORM
Requesting Agency
Primary Contact
Phone Number
Email
Name of Applicant/Former Employee
Applicant Former Employee
Date of Incident/Separation
Reason for Request:
Act of physical violence and/or serious threat of bodily harm
Theft or misappropriation of state property
Commission of a felony in the course of state employment
Act of abuse or neglect of a client, inmate, or other vulnerable person
Committed deception or fraud in the hiring process
Other (please specify):
Please provide a brief description of the incident that is resulting in this request:
Signature of Agency Head or Authorized Designee
Please submit this form electronically to:
Arizona Department of Administration
Human Resources Division
Email: HumanResources@azdoa.gov
FOR ADOA HRD USE ONLY
Disqualified
No Action/Return to Agency
Date
Date
EIN (if former employee)
ADOA HRD Deputy Director or Designee
ASPS/HRD-FA3.14 8/18
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