Fillable Employment Application (Illinois Secretary of State)

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Employment Application (Illinois Secretary of State)

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The Employment Application (Illinois Secretary of State) form is 6 pages long and contains:

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  • 270 other fields

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BROWSE ILLINOIS SECRETARY OF STATE FORMS

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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
1. ________________________________
2. ________________________________
3. ________________________________
OFFICE USE
TEST MONITOR
DRIVER’S LICENSE
■
PHOTO ID
■
OFFICE USE
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
■
Temporary
■
Social Security Number Date of Birth (optional)
Last Name First Name M.I.
Street Address
City State ZIP Code
Primary Telephone Number Alternate Telephone Number
(  ) (  )
EMAIL
Driver’s License
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
Employment Application
Print
Reset
2
SECTION I—Employment Information:
Child support obligations: State law requires that you provide certain information about child support obligations at the time of
hire. The possibility of employment is not affected by a child support obligation or default in payment.
Selective Service Registration: As a condition of employment, state law requires that “every male born on or after January 1,
1960, and less than 27 years old, shall submit documentation, at time of appointment, evidencing his registration with the Federal
Selective Service System.”
Disclosure of Information: The Office of the Secretary of State requests disclosure of information that is necessary to
accomplish the statutory purpose as outlined under 15 ILCS 310/10. Disclosure of this information is REQUIRED; failure to
provide any information may result in rejection of this form.
SECTION II—Experience Report:
Fully describe ALL of your work experience beginning with your present position. If you held several positions with one employer, list each
position separately. Incomplete information may negatively affect your grade for examinations consisting of training and experience.
Resumé format is not acceptable, but additional sheets may be attached. Additional sheets MUST include all information requested below.
Failure to fully complete the following information will result in no credit given for this work experience.
Name, Address and Phone Number of Employer: Payroll Title:
If this position was supervisory, indicate number of employees supervised for each type:
Manual/Trades Clerical/Office Technical/Paraprofessional Professional Administrative/Managerial
Failure to fully complete the following information will result in no credit given for this work experience.
Dates of Employment:
From: Mo Yr To: Mo Yr
Total: Years: Months: Average hours worked per week:
Describe your duties and responsibilities. Be specific.
Office Use Only
Reason for leaving: Level Amount
Failure to fully complete the following information will result in no credit given for this work experience.
Name, Address and Phone Number of Employer: Payroll Title:
If this position was supervisory, indicate number of employees supervised for each type:
Manual/Trades Clerical/Office Technical/Paraprofessional Professional Administrative/Managerial
Failure to fully complete the following information will result in no credit given for this work experience.
Dates of Employment:
From: Mo Yr To: Mo Yr
Total: Years: Months: Average hours worked per week:
Describe your duties and responsibilities. Be specific.
Office Use Only
Reason for leaving: Level Amount
3
Failure to fully complete the following information will result in no credit given for this work experience.
Name, Address and Phone Number of Employer: Payroll Title:
If this position was supervisory, indicate number of employees supervised for each type:
Manual/Trades Clerical/Office Technical/Paraprofessional Professional Administrative/Managerial
Failure to fully complete the following information will result in no credit given for this work experience.
Dates of Employment:
From: Mo Yr To: Mo Yr
Total: Years: Months: Average hours worked per week:
Describe your duties and responsibilities. Be specific.
Office Use Only
Reason for leaving: Level Amount
Failure to fully complete the following information will result in no credit given for this work experience.
Name, Address and Phone Number of Employer: Payroll Title:
If this position was supervisory, indicate number of employees supervised for each type:
Manual/Trades Clerical/Office Technical/Paraprofessional Professional Administrative/Managerial
Failure to fully complete the following information will result in no credit given for this work experience.
Dates of Employment:
From: Mo Yr To: Mo Yr
Total: Years: Months: Average hours worked per week:
Describe your duties and responsibilities. Be specific.
Office Use Only
Reason for leaving: Level Amount
4
Failure to fully complete the following information will result in no credit given for this work experience.
Name, Address and Phone Number of Employer: Payroll Title:
If this position was supervisory, indicate number of employees supervised for each type:
Manual/Trades Clerical/Office Technical/Paraprofessional Professional Administrative/Managerial
Failure to fully complete the following information will result in no credit given for this work experience.
Dates of Employment:
From: Mo Yr To: Mo Yr
Total: Years: Months: Average hours worked per week:
Describe your duties and responsibilities. Be specific.
Office Use Only
Reason for leaving: Level Amount
Failure to fully complete the following information will result in no credit given for this work experience.
Name, Address and Phone Number of Employer: Payroll Title:
If this position was supervisory, indicate number of employees supervised for each type:
Manual/Trades Clerical/Office Technical/Paraprofessional Professional Administrative/Managerial
Failure to fully complete the following information will result in no credit given for this work experience.
Dates of Employment:
From: Mo Yr To: Mo Yr
Total: Years: Months: Average hours worked per week:
Describe your duties and responsibilities. Be specific.
Office Use Only
Reason for leaving: Level Amount
5
Failure to fully complete the following information will result in no credit given for this work experience.
Name, Address and Phone Number of Employer: Payroll Title:
If this position was supervisory, indicate number of employees supervised for each type:
Manual/Trades Clerical/Office Technical/Paraprofessional Professional Administrative/Managerial
Failure to fully complete the following information will result in no credit given for this work experience.
Dates of Employment:
From: Mo Yr To: Mo Yr
Total: Years: Months: Average hours worked per week:
Describe your duties and responsibilities. Be specific.
Office Use Only
Reason for leaving: Level Amount
Failure to fully complete the following information will result in no credit given for this work experience.
Name, Address and Phone Number of Employer: Payroll Title:
If this position was supervisory, indicate number of employees supervised for each type:
Manual/Trades Clerical/Office Technical/Paraprofessional Professional Administrative/Managerial
Failure to fully complete the following information will result in no credit given for this work experience.
Dates of Employment:
From: Mo Yr To: Mo Yr
Total: Years: Months: Average hours worked per week:
Describe your duties and responsibilities. Be specific.
Office Use Only
Reason for leaving: Level Amount
* Any additional employment descriptions must include all information requested.
6
EDUCATION:
Qual Approved ________ Rejected _________
By __________________ Date ____________
Entry Date:
Exam Date (MM/DD/YR) Center
EDUCATION ________________ ________________
A ________________ ________________
B ________________ ________________
C ________________ ________________
TOTAL ________________
VET POINTS ________________ ________________
FINAL GRADE ________________
Remarks:
DEPARTMENT OF PERSONNEL USE ONLY
Title Code Written Keyboarding Vet Points Final Grade
SECTION VI—Foreign Language:
I am proficient (speak, write and translate) in the following languages (do not include English):
___________________________
____________________________
___________________________
1234
Name, Address and Phone Hours Earned: Major: Minor: Dates Attended: Degree Earned:
Number of College/University Sem Qtr Mo/Yr Mo/Yr Level Date: Mo/Yr
Undergraduate:
/ / / 
/ / /             
/ / /             
Graduate:           
/ / /             
Years Completed:
High School Graduate: YES ☐ NO ☐ OR GED: YES ☐ NO ☐
SECTION V—Education Report:
List college/university education accurately and completely. Proof of education claimed may be required during the hiring
process. A copy of a certified transcript/degree MUST be submitted to obtain credit for educational achievement for
training and experience evaluated titles.
Name, Address and Phone Number of From: To: Course Length:
Subject(s)
Certificate
Business, Trade, Technical or other School Mo/Yr Mo/Yr Hours/Days/Weeks Earned
/ / /          /
/ / /          /
SECTION IV—Business, Trade, Technical or Other Coursework:
List below coursework or classes taken that cannot be credited toward a college or university degree program. Failure to indicate
course length may result in no credit given.
Type: Certification Number: Date Issued: Expiration Date: State Issued In:
Mo Yr Mo Yr
Mo Yr Mo Yr
SECTION III—Professional/Technical Licensure or Certification:
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Employment Application (Illinois Secretary of State)

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Completed 28 May 2021

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