Human Resources APPLICANT INFORMATION FOR OFFICIAL USE ONLY Last First (Initial) Cell Phone Class Code: Home Phone Class Title: Reviewed by: Work Phone Agency: Accepted / Rejected Date: Reason: Email Address: *Social Security Number will be necessary for positions requiring examinations. In-House Posting? Yes: No: Position for which you are applying: Position Number (if known): Agency where position is located: Will you accept part-time employment? Yes No Will you accept employment anywhere in the State? Yes No If you in which you will accept employment: answered “NO”, please check up to 3 counties Merrimack Belknap Hillsborough Rockingham Cheshire Coos Strafford Sullivan Grafton Carroll DO YOU HAVE THE LEGAL RIGHT TO ACCEPT EMPLOYMENT IN THE UNITED STATES? Yes No Have you been employed by a NH State agency before? Yes No If yes, when? For what State agency were you employed? In what position? What was your reason for leaving? IF YOU HAVE EVER BEEN CONVICTED OF A CRIME (FELONY OR MISDEMEANOR) THAT HAS NOT BEEN OFFICIALLY ANNULLED BY A COURT, YOU MUST COMPLETE THE FOLLOWING SECTION, GIVING THE DATE, LOCATION AND NATURE OF THE FELONY OR MISDEMEANOR CONVICTION. If you leave this space blank, you are certifying that you have no current record of conviction. Please Note: Conviction is not an automatic disqualifier for employment. Each case is considered individually. WILLFUL OMISSION OR MISREPRESENTATION OF REQUIRED INFORMATION WILL BE A BASIS FOR REJECTION OF YOUR APPLICATION. EDUCATION
Human Resources APPLICANT INFORMATION FOR OFFICIAL USE ONLY Last First (Initial) Cell Phone Class Code: Home Phone Class Title: Reviewed by: Work Phone Agency: Accepted / Rejected Date: Reason: Email Address: *Social Security Number will be necessary for positions requiring examinations. In-House Posting? Yes: No: Position for which you are applying: Position Number (if known): Agency where position is located: Will you accept part-time employment? Yes No Will you accept employment anywhere in the State? Yes No If you answered “NO”, please check up to 3 counties in which you will accept employment: Merrimack Belknap Hillsborough Rockingham Cheshire Coos Strafford Sullivan Grafton Carroll DO YOU HAVE THE LEGAL RIGHT TO ACCEPT EMPLOYMENT IN THE UNITED STATES? Yes No Have you been employed by a NH State agency before? Yes No If yes, when? For what State agency were you employed? In what position? What was your reason for leaving? IF YOU HAVE EVER BEEN CONVICTED OF A CRIME (FELONY OR MISDEMEANOR) THAT HAS NOT BEEN OFFICIALLY ANNULLED BY A COURT, YOU MUST COMPLETE THE FOLLOWING SECTION, GIVING THE DATE, LOCATION AND NATURE OF THE FELONY OR MISDEMEANOR CONVICTION. If you leave this space blank, you are certifying that you have no current record of conviction. Please Note: Conviction is not an automatic disqualifier for employment. Each case is considered individually. WILLFUL OMISSION OR MISREPRESENTATION OF REQUIRED INFORMATION WILL BE A BASIS FOR REJECTION OF YOUR APPLICATION. EDUCATION