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STATE OF COLORADO DEMOGRAPHIC INFORMATION (Metropolitan State College of Denver)

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MARCH 2011
STATE OF COLORADO
DEMOGRAPHIC INFORMATION
PLEASE TYPE OR PRINT IN BLACK INK
A completed Announced Vacancy Application Form must be attached to this completed form.
NAME:
THE FOLLOWING INFORMATION IS CONFIDENTIAL
___________________Person ID (Agency Use only)
MAILING ADDRESS
:
FIRST CONTACT PHONE NUMBER:
SECOND CONTACT PHONE NUMBER:
E-MAIL ADDRESS:
VOLUNTARY INFORMATION
The information in this box is voluntary. Information is requested for federal record keeping purposes only. This sheet will be permanently separated from the rest of
your application. It is the policy of the state that its work force reflects the diversity of the state.
ETHNICITY/RACE
-
Please select one or more of the following
:
American Indian or Alaskan Native, not Hispanic or Latino
Hispanic or Latino
Asian, not Hispanic or Latino
Native Hawaiian or Pacific Islander, not Hispanic or Latino
Black or African American, not Hispanic or Latino
White or Caucasian, not Hispanic or Latino
Two or More Races, not Hispanic or Latino
GENDER
:
Male
Female
BIRTH DATE
:
Some state jobs have a legally required minimum age. Provide your entire birth date to be considered for these type(s) of jobs.
Month:
Day:
Year:
VETERAN'S PREFERENCE INFORMATION: Under the Colorado Constitution, art. XII, sec. 15, qualified veterans and surviving spouses are eligible for preference points
when taking a competitive examination, other than a promotional examination. If you are an honorably discharged veteran or unremarried surviving spouse of a veteran who served on
active duty in the United States Armed Forces during one of the periods for which the federal government awards veteran's preference points, you may claim points on a competitive
examination for a position with the state personnel system. Please attach a copy of a DD214 form and other supportive documentation for veteran's points to be awarded to your final
passing score(s). If you are a current or previous state employee you cannot claim veteran's preference points unless you earned the points after becoming a state employee.
1 - Disabled Veteran 2 - Veteran 3 – Disabled Vietnam Era Veteran 4 - Vietnam Era Veteran 5 - Unremarried Surviving Spouse
COLORADO DRIVER'S LICENSE:
BACKGROUND CHECK: If required for the job, would you be willing to submit to a background check?
Yes
No
STUDENT LOAN INFORMATION:
Do you have any outstanding loans or an obligation to a state-supported institution of higher education?
Yes
No
If yes, is this loan or obligation past due?
Yes
No
COLORADO IS AN EQUAL OPPORTUNITY EMPLOYER
MARCH 2011
STATE OF COLORADO
APPLICATION FOR ANNOUNCED VACANCY
A completed Demographic Information Form must be attached to this completed form when
submitted to the agency listed in the job announcement.
JOB TITLE AS ANNOUNCED:
CLASS CODE:
POSITION NUMBER:
AGENCY ANNOUNCING VACANCY:
NAME:
Last Name
First Name
Middle Name
Person ID (Agency Use
only):
Recruitment Information:
C
heck the one (1) that best describes how you learned about the job you have
applied for.
A. State of Colorado (CO-Jobs) website
I. Posted announcement at State Agency Office
B. State Agency website
J. Posted announcement at Workforce Center
C. Other website
K. Posted announcement at School Placement Office
D. Denver Post
L. Job Fair
E. Other newspaper
M. Friend/Relative
F. State Agency newspaper/newsletter
N. Current State Employee
G. Radio
O. Other
H. Television
FOR AGENCY USE ONLY
Application Received: Application Entered:
Application Reviewed:
ACCEPTED REJECTED CONDITIONAL ACCEPT
Reason for reject/conditional accept:
Education Experience Education and Experience Other
Second Review of Application: AGREE DISAGREE
MARCH 2011
NAME:
Person ID (Agency Use
only):
Job Title:
Position Number:
LICENSES/CERTIFICATION/REGISTRATIONS
: If a license/certificate/registration is required for the job for which you are applying (e.g.,
Journeyman Plumber, Professional Engineer, etc.) complete the following:
Professional/Specialty License Type:
License Number:
Expiration Date:
State and/or Agency Granting License:
LANGUAGE PROFICIENCY:
List language skills, other than English, you have and your level of proficiency (speak, read, write, etc.)
Language: Level of Proficiency:
EDUCATION HISTORY:
This section must be accurate and complete. The application is used to determine if you
meet the minimum job requirements as published in the job announcement.
High School Graduate:
Yes No GED: Yes No
UNIVERSITY/COLLEGE (UNDERGRADUATE, GRADUATE, POST GRADUATE)
Name: Location:
Attended From - To (Mo-Yr)
Degree Awarded:
Date:
Major Field of Study:
Minor Field of Study:
Total Semester Hours:
Name: Location:
Attended From - To (Mo-Yr)
Degree Awarded:
Date:
Major Field of Study:
Minor Field of Study:
Total Semester Hours:
Name: Location:
Attended From - To (Mo-Yr)
Degree Awarded
Date
Major Field of Study
Minor Field of Study
Total Semester Hours
BUSINESS, TRADE, TECHNICAL, VOCATIONAL SCHOOL OR MILITARY TRAINING
Name
Location:
Attended From - To (Mo-Yr)
Title of Program or Subjects Taken
Total Classroom Hours
Certificate Received
Yes No
Date
Name
Location: Attended From - To (Mo-Yr)
Title of Program or Subjects Taken
Total Classroom Hours
Certificate Received
Yes No
Date
MARCH 2011
NAME:
Person ID (
Agency Use
only):
Job Title:
Position Number:
EMPLOYMENT HISTORY
:
List your employment history starting with the most recent job, including part-time, temporary, and volunteer jobs. If more than one job was held with a
given organization, list each job held as a separate period of employment. Under "Duties," describe clearly the tasks you performed and the nature of your supervisory, technical, or other
responsibilities as they relate to the job for which you are applying. Be complete and specific in detailing of duties. Information must be accurate. If it is found that information provided is
falsified, you will not be considered for a job with the State of Colorado and/or may be removed from a job after hire. If you need additional space attach a separate sheet of paper using
the same format.
EMPLOYER/Kind of Business
Your Job Title
DATES OF EMPLOYMENT
Address(Street, City, State, Zip Code)
From: Mo Yr
Supervisor Name:
Title:
Phone:
To: Mo Yr
Duties: Hours Per Week
Monthly Salary $ .00
Number Professional
Employees Supervised:
0
Number Non-Professional
Employees Supervised:
0
Reason for Leaving:
EMPLOYER/Kind of Business
Your Job Title
DATES OF EMPLOYMENT
Address(Street, City, State, Zip Code)
From: Mo Yr
Supervisor Name:
Title:
Phone:
To: Mo Yr
Duties: Hours Per Week
Monthly Salary $ .00
Number Professional
Employees Supervised:
Number Non-Professional
Employees Supervised:
Reason for Leaving:
MARCH 2011
NAME:
Person ID (Agency Use
only):
Job Title:
Position Number:
EMPLOYER/Kind of Business
Your Job Title
DATES OF EMPLOYMENT
Address(Street, City, State, Zip Code)
From: Mo Yr
Supervisor Name:
Title:
Phone:
To: Mo Yr
Duties: Hours Per Week
Monthly Salary $ .00
Number Professional
Employees Supervised:
Number Non-Professional
Employees Supervised:
Reason for Leaving:
EMPLOYER/Kind of Business
Your Job Title
DATES OF EMPLOYMENT
Address(Street, City, State, Zip Code)
From: Mo Yr
Supervisor Name:
Title:
Phone:
To: Mo Yr
Duties: Hours Per Week
Monthly Salary $ .00
Number Professional
Employees Supervised:
Number Non-Professional
Employees Supervised:
Reason for Leaving:
MARCH 2011
NAME:
Person ID (Agency Use
only):
Job Title:
Position Number:
EMPLOYER/Kind of Business
Your Job Title
DATES OF EMPLOYMENT
Address(Street, City, State, Zip Code)
From: Mo Yr
Supervisor Name:
Title:
Phone:
To: Mo Yr
Duties:
Hours Per Week
Monthly Salary $ .00
Number Professional
Employees Supervised:
Number Non-Professional
Employees Supervised:
Reason for Leaving:
EMPLOYER/Kind of Business
Your Job Title
DATES OF EMPLOYMENT
Address(Street, City, State, Zip Code)
From: Mo Yr
Supervisor Name:
Title:
Phone:
To: Mo Yr
Duties: Hours Per Week
Monthly Salary $ .00
Number Professional
Employees Supervised:
Number Non-Professional
Employees Supervised:
Reason for Leaving:
MARCH 2011
NAME:
Person ID (Agency Use
only):
Job Title:
Position Number:
EMPLOYER/Kind of Business
Your Job Title
DATES OF EMPLOYMENT
Address(Street, City, State, Zip Code)
From: Mo Yr
Supervisor Name:
Title:
Phone:
To: Mo Yr
Duties: Hours Per Week
Monthly Salary $ .00
Number Professional
Employees Supervised:
Number Non-Professional
Employees Supervised:
Reason for Leaving:
REFERENCES:
List three persons who are not related to you and who have definite knowledge of your business or professional qualifications for the job for which you are applying.
Do not repeat names of supervisors listed under work history. They may be contacted as well.
Name
Business/Occupation
Relationship
Address (Street, City, State, Zip Code)
Phone
Name
Business/Occupation
Relationship
Address (Street, City, State, Zip Code)
Phone
Name
Business/Occupation
Relationship
Address (Street, City, State, Zip Code)
Phone
CERTIFICATION: I certify that I possess the experience, education and/or licenses required for the job for which I am applying. I also certify that all statements, information and
documents provided with this application are true, complete and correct to the best of my knowledge and are made in good faith. I understand that omissions, misleading, false or untrue
information, or any attempt at fraud or deceit in any manner connected with this application and subsequent testing may result in my NOT being considered for jobs with the State of
Colorado; may constitute grounds for discipline and/or termination after hire; and/or may constitute grounds for further actions pursuant to law. If requested, I can and will supply
documentation that will confirm that the entries made on this application are true, complete and correct. Notice to Individuals applying for employment with a child care provider or facility,
per Colorado Revised Statutes (C.R.S) §26-6-105.5, “Any applicant who knowingly or willfully makes a false statement of any material fact or thing in this application is guilty of perjury in
the second degree as defined in section 18-8-503, Colorado Revised Statutes, and, upon conviction thereof, shall be punished accordingly.” I am also aware that the State of Colorado
has a payroll direct deposit requirement for employment. When needed I can supply the correct documentation for direct deposit.
Signature (unsigned applications may not be considered) Date
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STATE OF COLORADO DEMOGRAPHIC INFORMATION (Metropolitan State College of Denver)

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Completed 18 September 2020

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