Fillable Criminal Convictions Addendum To Application For Examination Or Employment Form CT HR 13 (State of Connecticut/Department of Administrative Services)

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Criminal Convictions Addendum To Application For Examination Or Employment Form CT HR 13 (State of Connecticut/Department of Administrative Services)

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ADDENDUM TO THE APPLICATION FOR EXAMINATION
OR EMPLOYMENT CT-HR-13 NEW 10/1/2010
STATE OF CONNECTICUT
Addendum to the Application for Examination or Employment (CT-HR-13)
CRIMINAL CONVICTIONS
INSTRUCTIONS TO APPLICANT: You are required to complete this form if the job/position posting
states that you must fill out the CRIMINAL CONVICTIONS form (CT-HR-13) or you are requested to
fill out the form by a hiring agency. Answers to the following question will be considered for
employment purposes if relevant to the position for which
you are applying. Per C.G.S. § 46a-80:
SECTION 1: APPLICANT INFORMATION
_______________________________ _____________________ ___ ______
LAST NAME FIRST NAME MI SUFFIX (i.e., Jr., MD, Ph.D.)
_________________________________________________________ ____________________
MAILING ADDRESS (P.O. Box # or house number and street) APARTMENT # (if any)
_______________________________________________ ______ _________________
CITY STATE ZIP CODE
____________________________________________
SOCIAL SECURITY NUMBER
If name was different, list all name(s) used. Include last name, first name and middle initial for each.
_____________________________________ ______________________________________
_________________________________________ ___________________________________________
SECTION 2: APPLICANT CERTIFICATION
I certify that the statements made by me on this application form and attachments, if any, are true and
complete to the best of my knowledge and are made in good faith. I understand that if I knowingly
make any misstatement of fact, I am subject to disqualification and dismissal and to such other
penalties as may be prescribed by law or personnel regulations. All statements made on this
application, including employment information, are subject to verification as a condition of
employment.
Applicant signature: __________________________________ Date: ____________
(Signature is required)
Note: A typed name will substitute for a handwritten signature.
PAGE TWO _________________________________ ____________________ ____
Last Name First Name MI
SECTION 3: CRIMINAL CONVICTIONS
Have you ever been CONVICTED of an offense against criminal or military law, or are there criminal charges
currently pending against you? (Exclude minor traffic violations or any offense settled in juvenile court or under
a youth offender law.) ___ Yes ___ No
If you answered "Yes", please provide a detailed explanation below about the nature of the conviction, degree
of rehabilitation and time since release. Attach an additional sheet of paper if necessary.
Special Note: You are not required to disclose the existence of any arrest, criminal charge or conviction, the
records of which have been erased pursuant to Connecticut General Statutes § 46b-146, 54-76o, or 54-142a.
If your criminal records have been erased pursuant to one of these statutes, you may swear under oath that
you have never been arrested. Criminal records that may be erased are records pertaining to a finding of
delinquency or that a child was a member of a family with service needs (C.G.S. § 46b-146), an adjudication
as a youthful offender (C.G.S. § 54-76o), a criminal charge that has been dismissed or nolled, a criminal
charge for which the person has been found not guilty or a conviction for which the person received an
absolute pardon (C.G.S. § 54-142a).
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Criminal Convictions Addendum To Application For Examination Or Employment Form CT HR 13 (State of ConnecticutDepartment of Administrative Services)

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Completed 16 July 2020

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