P R I N T O R T Y P E O N L Y
County of Residence
Work Co. or Cook Co. Zone Preference
State Issued: Class Rating — Non-CDL: Class Rating — CDL: Driver’s License Number: Date Expires:
MO DY YR
DEPARTMENT OF PERSONNEL USE ONLY
VETERANS POINTS AND PREFERENCE
This application is for permanent, intermittent or temporary employment only. Complete this application in detail. A separate application is required for each title
that requires a training and experience evaluation; previous applications will not be reconsidered. Mail completed applications for training and experience testing
to: Secretary of State, Department of Personnel, 196 Howlett, Springfield, IL 62756 or 17 N. State St., Ste. 1300, Chicago, IL 60602. Incomplete applications
may be rejected. Bring a completed application and photo identification with each visit to a test site if this application is used for written/performance examinations.
I understand that I may be required to submit proof of previous employment, education or any other statement(s) in this application. I
hereby authorize the release of this and associated information covering job-related factors for purposes of verification and
determination of suitability for state employment by means of a background check. I certify that the information on this application
is true and accurate to the best of my knowledge, and understand that misrepresentation of any information herein may result in
ineligibility or be grounds for discipline, up to and including discharge.
Written Signature of Applicant (signature required) Date
THE OFFICE OF THE SECRETARY OF STATE IS AN EQUAL OPPORTUNITY EMPLOYER.
Printed by authority of the State of Illinois. March 2021 — 2M — Per D 81.22
☐ I wish to claim Veterans Preference: Attach U.S. Veterans Affairs award letter or a legible copy of a certified DD214/215.
☐ I wish to claim Veterans Preference as a member of the Illinois National Guard or U.S. Armed Forces Reserves: Attach letter
from unit personnel indicating service under honorable conditions or a legible copy of a certified NGB 22.
☐ I have already established Veterans Preference with the Office of the Secretary of State.
To claim Veterans Preference as a surviving spouse or parent of an unmarried veteran who suffered service-connected death or
disability, attach completed Spouse/Parent Eligibility for Veterans Preference form.
Title of Position Applied For I will accept: Intermittent
Social Security Number Date of Birth (optional)
Last Name First Name M.I.
City State ZIP Code
Primary Telephone Number Alternate Telephone Number
( ) ( )
APPLICATIONS WILL NOT BE ACCEPTED UNLESS ALL QUESTIONS ARE ANSWERED
AND REQUIRED ATTACHMENTS ARE SUBMITTED
1. Have you ever pleaded guilty, been found guilty or been convicted of any criminal offense other
than a minor traffic violation? YES ☐ NO ☐
2. Have you ever been discharged from a job? Layoff/downsizing does not apply. YES ☐ NO ☐
(If “YES,” to 1 or 2 above attach detailed
explanation or complete Background Disclosure form.)*
3. Are you currently in default on repayment of any state education loan?** YES ☐ NO ☐
4. Is any member of your family employed by the Office of the Secretary of State?*** YES ☐ NO ☐
(If “YES,” Name of Employee _______________________________ Dept.________________ Relationship _______________)
* Pursuant to Illinois law, all applicants, except those seeking employment in law enforcement positions, are not obligated to disclose an arrest or conviction record
that has been expunged or sealed, or where you received supervision and successfully completed it.
** 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
employment, make satisfactory repayment arrangements with the maker or guarantor of the loan.
*** Family Member includes a person who has established a party to a civil union or parties to a marriage pursuant to the law.
Office of the Secretary of State
Department of Personnel