Social Security Number Date of Birth (Optional)
Last Name First Name Middle Initial
Street Address
City State ZIP Code
Primary Telephone Number Alternate Telephone Number
( ) ( )
DRIVER’S LICENSE
1
State of Illinois
Office of the Secretary of State
DEPARTMENT OF PERSONNEL
I authorize release of any information supplied on this application for purposes of verification and determination of suitability for
Student Worker employment through a background check. I certify that the information, education and work experience listed on
this application is true and accurate to the best of my knowledge, and I understand that misrepresentation of any material may
be grounds for ineligibility or termination of employment.
__________________________________________________________ _________________________________
Written Signature of Applicant (REQUIRED) Date
THE OFFICE OF THE SECRETARY OF STATE IS AN EQUAL OPPORTUNITY EMPLOYER.
APPLICATIONS WILL NOT BE ACCEPTED UNLESS ALL QUESTIONS ARE ANSWERED AND
REQUIRED ATTACHMENTS ARE SUBMITTED.
1. Have you ever been discharged from a job?
(If “YES,” attach detailed explanation; layoff/downsizing does not apply.)
2. Have you ever pled guilty, been found guilty or been convicted of any criminal offense other than a
minor traffic violation? (If “YES,” attach statement with date(s), charge(s) and sentence(s).
Expunged or sealed convictions need not be disclosed.)
3. Are you currently in default on repayment of any state education loan?*
4. Is any member of your family employed by the Office of the Secretary of State?
(If ‘YES,” please state: NAME OF EMPLOYEE:______________________ RELATIONSHIP:______________________)
*State law requires an employee in default on repayment of any education loan for 6 months or more and in the amount of $600 or more shall, as a condition of employ-
ment, make satisfactory repayment arrangements with the maker or guarantor of the loan.
YES ___ NO ___
YES ___ NO ___
YES ___ NO ___
YES ___ NO ___
Student Worker (Metro) Employment Application
S e c t i o n I — P R I N T O R T Y P E O N L Y
State Issued Class Rating-Non-CDL Class Rating-CDL Driver’s License Number Date Expires
MO DY YR
Printed by authority of the State of Illinois. March 2017 – 500 – Per D 136.7
County of Residence
List the location in which you wish to
work: (see attached list)
1.________________________________
2.________________________________
3.________________________________
You MUST list a locality preference to be
considered for this program.
IMPORTANT NOTICE: To be eligible for the Student Worker Program you MUST be enrolled as a student for the following
school year. APPLICANT MUST indicate below where he/she is enrolled or intends to enroll for continued education.
I am currently enrolled in:
n
High School
n
College
In September, I will be enrolled in:
n
High School
n
College
Name of School/College:
_______________________________________________________________________________
Your application will be returned if this information is not provided.
