STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

1 CS-9 REV. 6/09. STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS . DEPARTMENT OF ADMINISTRATION FOR HUMAN RESOURCES USE. DIVISION OF HUMAN RESOURCES. OFFICE OF PERSONNEL ADMINISTRATION ONLY. One Capitol Hill APPLICATION # _____. TELEPHONE: 222-2172 PROVIDENCE , RHODE ISLAND 02908-5860. RI RELAY 711. AN EQUAL OPPORTUNITY EMPLOYER IMPORTANT: RESIDENCY REQUIREMENT (REF GL 36-4-18). INSTRUCTIONS: Only that information specifically listed on this application will DO NOT WRITE IN THIS BLOCK. be considered in determining your qualifications for the examinations for which SOCIAL SECURITY NUMBER_____ FOR OFFICIAL USE ONLY. you have applied. Insufficient information may result in rejection from an NOTE: Providing your Social Security Number is voluntary in accordance with the Privacy examination or a lower score on your Education and Experience rating.

2 Act of 1974. Your cooperation is encouraged, as this information is necessary for VPTS: _____ Init: _____. The Office of Personnel Administration reserves the right to investigate all properly crediting you with veteran's credit or bonus points for determining eligibility for statements made on your application, and to require proof of such statements promotional examinations in accordance with STATE Law. Prom: _____ Stat: _____. when deemed necessary. Any individual with a disability who requires NAME_____ Lang: _____. assistance during the exam process should notify the Examination Section 7 FIRST MI LAST. Days in advance to ensure that appropriate accommodations will be made. Class: _____. RESIDENCE _____. Retain a copy of this application for your records, as it will not be returned MAILING ADDRESS.

3 To you. Attach additional pages if needed. Base: _____. _____. PLEASE PRINT OR TYPE ALL INFORMATION LEGIBLY CITY STATE ZIP CODE. Init: _____. TELEPHONE _____. HOME CELL Date: _____. COMPLETE THIS SECTION ONLY IF YOU CLAIM TO BE A Serial: _____. List the TITLE AND NUMBER of each exam for which you are applying. WAR VETERAN. _____ _____. WAR TIME SERVICE DATES APPLICABLE UNDER 1. _____ _____. RHODE ISLAND LAW (Ref GL 36-4-19): _____ _____. 12/7/41 - 12/31/46 8/20/82 - 12/31/87. 2. _____ _____. 6/27/50 - 1/31/55 12/20/89 - 1/31/90 _____ _____. 7/1/58 - 1/1/59 8/2/90 - 7/13/92. 3. _____ _____. 8/5/64 - 5/7/75 _____ _____. 4. _____ _____. If disabled veteran, Claim Number: _____. If you claim veteran's credit, attach a copy of your separation papers (usually Form DD-214) _____ _____ _____.

4 To this application. If you are also a Disabled Veteran, attach a copy of Form FL 21-802. (Disabled Veteran's Preference Form). THE PAPERS WILL NOT BE RETURNED TO YOU. _____ _____ _____ _____. Only with the required papers will you receive veteran's service credit. _____ _____. CHECK THOSE LANGUAGES IN WHICH YOU ARE FLUENT: _____ _____. ____ ENGLISH ____ PORTUGUESE ____ SPANISH ____ THAI ____ VIETNAMESE. ____ FRENCH ____ HMONG ____ CAMBODIAN ____ ITALIAN ____ LAO. ____ SIGN LANGUAGE ____ OTHER (specify) _____. NOTE: YOU are responsible for applications sent through the mail. COMPLETION OF THE SIGNATURE BLOCK IS REQUIRED. UNSIGNED APPLICATIONS WILL BE RETURNED UNPROCESSED. I certify to the truth and completeness of all statements made on this application.

5 I have read and understand the instructions as specified on this application, and recognize that any false or deceptive statement or omission of material fact may bar me from examination(s) or may result in my removal from appropriate civil service lists or my dismissal from STATE Service. _____ _____. Signature Date CS-9 REV. 6/09. EDUCATION & EXPERIENCE: Read the minimum qualifications of the exam announcement before completing these sections. EDUCATION: CIRCLE HIGHEST GRADE COMPLETED Are you a high school graduate? Yes____ No_____. 8 9 10 11 12 1 2 3 1 2 3 4 1 2 3 4 High school equivalency (GED)? Yes____ No_____. Elem/high school post high school/ college grad. School Are you a college graduate? Yes ____ No _____. vocational List in reverse chronological order (most recent education first): Colleges and universities, technical, vocational, or trade schools, and high schools attended.

6 Name and address Major and/or Dates attended Type of diploma or If no degree, of Institution course of study From To degree earned # of credits Courses pertinent to this exam:(give course title and number of credits) STATE In-service Training Courses (give course title and number of credits). _____ _____ _____. _____ _____ _____. _____ _____ _____. _____ _____ _____. _____ _____ _____. Professional licenses held:_____. _____. EXPERIENCE: Begin with your most recent or current employment experience. List all experience in detail, including all requested information for each period of employment appearing on this application. Describe the duties personally performed by you and include information about the number and types of employees supervised, if any.

7 Resum s may be attached to provide supplemental information, and additional sheets may be included if necessary. DATES EMPLOYED: A. EMPLOYER NAME & ADDRESS:_____ FROM: _____. TO: _____. SUPERVISOR'S TITLE: YOUR POSITION TITLE: TOTAL TIME IN POSITION. DUTIES_____ _____ YEARS. _____ _____ MONTHS. _____. _____ # of hours per week _____. _____. _____ ANNUAL SALARY: _____ $_____. _____. NUMBER AND TYPES OF EMPLOYEES SUPERVISED: _____. _____FOR HOW LONG? _____. CS-9 REV. 6/09. DATES EMPLOYED: B. EMPLOYER NAME & ADDRESS: FROM: _____. _____. TO: _____. SUPERVISOR'S TITLE: YOUR POSITION TITLE: TOTAL TIME IN POSITION. DUTIES_____ _____ YEARS. _____ _____ MONTHS. _____. _____ # of hours per week _____. _____. _____ ANNUAL SALARY: _____ $_____.

8 _____. NUMBER AND TYPES OF EMPLOYEES SUPERVISED: _____. _____FOR HOW LONG? _____.. DATES EMPLOYED: C. EMPLOYER NAME & ADDRESS:_____ FROM: _____. TO: _____. SUPERVISOR'S TITLE: YOUR POSITION TITLE: TOTAL TIME IN POSITION. DUTIES_____ _____ YEARS. _____ _____ MONTHS. _____. _____ # of hours per week _____. _____. _____ ANNUAL SALARY: _____ $_____. _____. NUMBER AND TYPES OF EMPLOYEES SUPERVISED: _____. _____FOR HOW LONG? _____. CS-9 REV. 6/09. DATES EMPLOYED: D. EMPLOYER NAME & ADDRESS: FROM: _____. _____. TO: _____. SUPERVISOR'S TITLE: YOUR POSITION TITLE: TOTAL TIME IN POSITION. DUTIES_____ _____ YEARS. _____ _____ MONTHS. _____. _____ # of hours per week _____. _____. _____ ANNUAL SALARY: _____ $_____. _____. NUMBER AND TYPES OF EMPLOYEES SUPERVISED: _____.

9 _____FOR HOW LONG? _____.. DATES EMPLOYED: E. EMPLOYER NAME & ADDRESS:_____ FROM: _____. TO: _____. SUPERVISOR'S TITLE: YOUR POSITION TITLE: TOTAL TIME IN POSITION. DUTIES_____ _____ YEARS. _____ _____ MONTHS. _____. _____ # of hours per week _____. _____. _____ ANNUAL SALARY: _____ $_____. _____. NUMBER AND TYPES OF EMPLOYEES SUPERVISED: _____. _____FOR HOW LONG? _____.