Fillable STATE OF NEW JERSEY Application for Employment (State of New Jersey)

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STATE OF NEW JERSEY Application for Employment (State of New Jersey)

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The Opportunity to Compete Act, N.J.S.A. 34:6B-11 to 19, went into effect on March 1, 2015. Under this
new law, an employer cannot make any inquiry—either verbally or in writing, including in an employment
application—about an applicant’s criminal record during the Initial Employment Application Process, unless
one of the limited exceptions below applies.
The Initial Employment Application Process refers to “the period beginning when an applicant for
employment fi rst makes an inquiry to an employer about a prospective employment position or job vacancy
or when an employer fi rst makes any inquiry to an applicant for employment about a prospective employment
position or job vacancy, and ending when an employer has conducted a fi rst interview, whether in person
or by any other means, of an applicant for employment.” Employers can make this inquiry after the Initial
Employment Application Process has concluded (i.e., post-interview).
The Act allows employers to request criminal history information before the fi rst interview in the following
limited circumstances:
• If an applicant voluntarily discloses his or her criminal history during the Initial Employment
Application Process.
• Where the applicant is seeking a position in law enforcement, corrections, the judiciary, homeland
security or emergency management.
• Where the applicant is seeking a position where a criminal history record background check is
required by law, rule or regulation.
• Where the applicant may be legally precluded from holding the position by virtue of his or her arrest
or conviction.
• Where any law, rule or regulation restricts an employer’s ability to engage in specifi ed business
activities based on the criminal records of its employees.
• Where the applicant is seeking a position designated by the employer as part of a program designed
predominately to encourage the employment of persons who have a criminal record.
* If application is used before the Initial Employment Application Process, question #11 should not be answered.
Question #11 of the application seeks information on convictions that have not been expunged. Accordingly,
unless one of the above exceptions applies, the application shall only be used after the
Initial Employment
Application Process
.
Job applicants are considered for all positions without regard to race, creed, color, national origin, sex,
affectional or sexual orientation, age, religion, marital, or veterans status, or disability. The State will not
tolerate any form of discrimination or sexual harassment.
The Americans with Disabilities Act of 1990 as amended prohibits employers from discriminating against
any qualifi ed person on the basis of a disability. The State of New Jersey makes reasonable accommodations
during all aspects of the employment process, such as testing and interviews. The State also makes
reasonable accommodations in the work environment to enable a person with a disability to perform the
essential job functions and to participate equally with co-workers without disabilities. However, the State
can only make reasonable accommodations when it is aware of a disability. It is up to you to inform
the prospective employer if you need a reasonable accommodation. The employer may ask you for
documentation to support your request for a reasonable accommodation.
APPLICANT -- DO NOT COMPLETE THIS SECTION
Name: (Last, First, MI.) Position Title: Department: Division:
STATE OF NEW JERSEY
Application for Employment
The State of New Jersey is an Equal Opportunity Employer
DPF-663 Revised 2.9.18
Page 1
Please PRINT or TYPE answers. Feel free to add any information which will help to place you.
Please be aware that misrepresentation may be cause for removal.
1. Name (Last, First, MI) 2. Home Phone Number (Area Code) 3. Work Phone Number (Area Code)
4a. Address:
Number, Street, Apartment Number, etc.
4b. If entry in 4a is your mailing address only, enter name of
street, township, city or borough in which you live.
City: County:
State: Zip Code:
5. Position applying for (or type of work you are interested in)
Proof of Age, Education, Military Status, and Citizenship may be required upon employment offer
6. In what state regions are you willing to work? “X” all that apply:
NORTHERN
CENTRAL
SOUTHERN
7. Indicate preferred work schedule:

Full-Time
Part-Time
Temporary
Days
Evenings
Late Nights
Any Shift
Rotating Shift
8. Are you 18 years old or older?
(if under 18, you will be required to submit working papers if offered employment.)
Yes
No
9a. Do you possess a driver’s license that is valid in New Jersey?
Yes
No
9b. Do you possess a Commercial Driver License?
Yes
No
(Answer these questions only if it is a requirement as indicated on the job announcement or job specifi cation)
10. Are you either a U.S. citizen or an alien authorized to work in the U.S.?
Yes
No
*Review instructions on cover before answering this question.
11. Have you ever been convicted of a crime or other offense which has not been expunged by the Court, either in New Jersey or in
any other jurisdiction?
( A conviction will not necessarily preclude you from employment.)

Yes (
if yes, give details in Block Number 16) No
12. Are you a Veteran?
Yes
No
If yes, have you established Civil Service Veteran’s Preference with the NJ Civil Service Commission between April 1, 1980 and
March 1, 2001 or with the NJ Department of Military and Veteran after March 1, 2001?
Yes
No
13. Are you now or have you ever been a member of any Public Employee’s Retirement System?
Yes
No
(If yes, indicate system name and membership number in Block Number 16)
14. Have you ever worked or been educated under a different name?
Yes (if yes, specify here: ____________________
No
15. Are you currently on a special or regular reemployment list, or any list resulting from an examination administered by the
New Jersey Civil Service Commission?
Yes
No *If yes, indicate Titles and Symbols here: _____________________________
16. Explanations (Use this block for explanations to questions. Attach additional sheets if necessary.)
17. EDUCATION/SKILL HISTORY:
Please list all vocational, technical, correspondence schools, colleges and universities you have
attended. Upon employment be prepared to provide supporting documentation of schools attended. Attach additional sheets if necessary.

Circle the number indicating the highest grade of school you have completed:
1 2 3 4 5 6 7 8 HIGH SCHOOL 9 10 11 12 GED COLLEGE 1 2 3 4 Graduate1 2 3 4 5 6
Name and Address of School Did you
Graduate?
Credit Hours
Earned
Major Subject Number of
Credits in
Major
Degree
Received
High School last attended:
Yes
No
College or University:
Yes
No
Graduate School:
Yes
No
Other Formal Training (include Military):
Yes
No
Page 2
18. FOREIGN LANGUAGE ABILITIES: (Answer is Optional) If there are any foreign languages, including sign languages, in which
you are profi cient enough to communicate on a job, and are willing to use on the job (now and in the future), please list them here.
19. CLERICAL SKILLS:
(a) Typing?
Yes
No WPM: _____
(b) Stenography?
Yes
No WPM: _____
Offi ce machines operated, computer systems/software used, and/or special skills
20. List all employment starting with present or last position and work back, including military experience.
PLEASE PRINT OR TYPE, USE ADDITIONAL SHEETS IF NECESSARY.
From:
Month:
Year:
To:
Month:
Year:
Position Title:
Give number of staff
supervised if any:
Supervisor’s Name:
Telephone Number:
Employer’s Name and Complete Address:
Full Time
Part Time
List number of hours per week: ___________
Reason for Leaving:
Description of Duties:
From:
Month:
Year:
To:
Month:
Year:
Position Title:
Give number of staff
supervised if any:
Supervisor’s Name:
Telephone Number:
Employer’s Name and Complete Address:
Full Time
Part Time
List number of hours per week:___________
Reason for Leaving:
Description of Duties:
From:
Month:
Year:
To:
Month:
Year:
Position Title:
Give number of staff
supervised if any:
Supervisor’s Name:
Telephone Number:
Employer’s Name and Complete Address:
Full Time
Part Time
List number of hours per week:___________
Reason for Leaving:
Description of Duties:
May we contact all employer/supervisors listed?
Yes
No (Indicate exceptions):
21. Attach additional sheets to describe any internships, licenses, certifi cations or registrations
related to the position for which you are applying. Give name of the State in which license,
certifi cation or registration is held or dates and location of internship. If specifi c license or certifi cation
is required for your position, you will be required to present the appropriate credential(s) prior to
employment, and you will be responsible to renew the credential(s) and advise the personnel offi ce if
the credential(s) expires or is revoked.
Page 3
GENERAL INFORMATION (Please print or type. Use additional sheets if necessary.)
22. Are you engaged in any business activity or employment which you plan to continue if employed by the State?
If yes, your outside employment will be subject to further review regarding confl icts of interest.
No
Yes
If yes, explain:
23. Please add any additional information which will help in placing you where you are best qualifi ed. Include such items as: honors,
hobbies, publications, volunteer work, public speaking and writing experience, membership in professional or scientifi c societies.
24. List three people unrelated to you whom we may contact for information concerning your qualifi cations.
Name:
Address:
Phone Number:
Occupation:
Name:
Address:
Phone Number:
Occupation:
Name:
Address:
Phone Number:
Occupation:
Please indicate a telephone number where and at what time you may be contacted for an interview:
I understand that if I plan to engage in other business or employment while working for the State in any of its Departments or
Agencies, prior approval will be necessary before accepting employment since there may be restrictions in accordance with the
New Jersey Confl icts of Interest Law and/or the State, Department or Agency Code of Ethics.
I authorize my former employers to release any information they may have concerning my employment record and I release the
State of New Jersey and all previous employers listed above from all liability whatsoever that may issue from securing this information.
I further authorize representatives of this agency to verify any and all information contained in this application, including education,
and to review any and all criminal history, military and disciplinary records of any source.
I CERTIFY that the information on this application is complete and accurate, to the best of my knowledge. I understand that any
misleading or incorrect information may render this application void and be just cause for immediate termination if employed.
Signature: ___________________________________ Date: _______________
THIS SECTION FOR PERSONNEL OFFICE USE ONLY
STOP:
Please Return Completed
Application to the Personnel Offi ce
STATE OF NEW JERSEY
AFFIRMATIVE ACTION INFORMATION FORM
The State of New Jersey is an Equal Opportunity Employer
DPF-663 AAIF Revised 04-28-10
To Be Completed By Applicant
Not For Interview Purposes
To Be Filed Separately With
Affi rmative Action Offi cer
GENDER:
Male
Female
The State of New Jersey seeks to increase the richness and diversity of its workforce and in doing so become the employer
of choice for all people seeking to work in State government. In order to judge the effectiveness of our efforts to attract and
employ a diverse workforce, as well as comply with Federal and State reporting requirements, we ask that you take the time
to answer a few brief questions.
This form is not part of your application for employment and will not be considered in any hiring decision. Any information
submitted on this form will be considered confi dential and will be fi led separately by the agency’s affi rmative action offi cer.
The State of New Jersey is an equal opportunity employer. The New Jersey State Policy Prohibiting Discrimination in the
Workplace provides that applicants for employment are considered without regard to race, creed, color, national origin,
nationality, ancestry, sex/gender, affectional or sexual orientation, gender identity or expression, age, marital status, civil
union status, domestic partnership status, familial status, religion, atypical heredity cellular or blood trait, genetic information,
liability for service in the Armed Forces of the United States or disability.
A. Ethnicity: (Please Select One)
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South
or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic or Latino
B. Race: (Please Select one)
Black or African American: A person having origins in any
of the black racial groups of Africa.
Native Hawaiian or Other Pacifi c Islander: A person having
origins in any of the original peoples of Hawaii, Guam, Samoa,
or other Pacifi c Islands.
White: A person having origins in any of the original peoples of
Europe, the Middle East, or North Africa.
The EEOC has recently updated its data collection requirements to allow employees who may be of two or more races to identify themselves.
If you are of more than one race please identify them below.
C. Two or More Races: (If applicable, select the two or more races with which you identify)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacifi c Islander
White
If you require an accommodation for the interview process please advise the HR representative at the department where
you are applying for the job.

American Indian or Alaska Native: A person having origins in any
of the original peoples of North and South America (including Central
America), who maintains tribal affi liation or community attachment.
Asian: A person having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent including, for
example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand and Vietnam.
DATE:
POSITION(S) APPLIED FOR:
DIVISION:
APPLICANT NAME: (Last, First, M) APPLICANT ADDRESS:
REFERRAL SOURCE:
How did you learn of this position?
PHILIP D. MURPHY Office of Information Technology
Governor P.O. Box 212
Trenton, New Jersey 08625-0212
SHEILA Y. OLIVER CHRISTOPHER J. REIN
Lt. Governor Chief Technology Officer
05/30/2018
RELATIVES DISCLOSURE STATEMENT
The New Jersey Office of Information Technology does not employ persons into positions that are supervised
by or have influence or control by a relative through blood, marriage, legal action, or domestic partnership.
Individuals are required to list all as defined above who work in the Office of Information Technology at the
time of application for work. If relationships covered by this policy occur after employment, employees are
required to forward written notification to the Human Resource Office immediately upon determining the
existence of the relationship.
Failure to provide the notification may result in disciplinary action in accordance with the New Jersey Office
of Information Technology and may include dismissal of the employee.
I do not have blood, marriage, legal action, or domestic partnership relatives working for
the New Jersey Office of Information Technology.
The following blood, marriage, legal action, or domestic partnership relative’s work
for the New Jersey Office of Information Technology:
NAME
RELATIONSHIP
WORK LOCATION
Applicant’s Name: _____________________________________________________________
(Please Print)
Applicant’s Signature: __________________________________________________________
Date: ___________________________
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STATE OF NEW JERSEY Application for Employment (State of New Jersey)

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Completed 27 September 2021

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