Full Name First Middle Last

Mailing Address House or Apartment Number Street

City State County Zip Code E-mail Address

Telephone Number: Home Cell Work Area Code Area Code Area Code

The following information is required for governmental reporting or record keeping purposes: Date of Bi rth __ Sex (check one) 1. Male Female

(Month) (Day) (Year)

Race (check one) :KLWH %ODFN +LVSDQLF $VLDQ 1DWLYH +DZDLLDQ RU 3DFL F,VODQGHU $PHULFDQ,QGLDQ RU $ODVNDQ 1DWLYH Two or More Races Do Not Wish to Respond

A P P L I C A T I O N F O R E X A M I N A T I O N

RETURN TO: STATE OF ALABAMA

PERSONNEL DEPARTMENT

MONTGOMERY, ALABAMA 36130-4100

WWW.PERSONNEL.ALABAMA.GOV

FAX: 334-***-****

Form 3 – Revised April. 2021

DO NOT WRITE IN THIS SPACE

Job Title of Examination (one per application): Option (if applicable): EDUCATION:

High School Diploma or GED? Yes No

CIRCLE OR BRACKET THE HIGHEST GRADE OF SCHOOL COMPLETED. 1 2 3 4 5 6 7 8 9 10 11 12 C o lllll 1 2 3 4

ED

LC

PROVIDE INFORMATION ON ALL SCHOOLS ATTENDED. SPECIFY UNDERGRADUATE OR GRADUATE WORK. IF ONLINE, INDICATE BY *ASTERISK. Dates of Attendance Credit Hours Did You

Month/Year Earned Graduate? Type of Degree

Name and Location of School From To Sem. Qtr. Yes No and Date Major PROFESSIONAL LICENSE OR CERTIFICATE

LIST COURSES SUCCESSFULLY COMPLETED (AND HOURS EARNED) WHICH ARE PARTICULARLY RELATED TO POSITION (attach additional sheets, if needed) CERTIFICATION STATEMENT

agree and understand that any false or deceptive information herein, regardless of time of discovery, may cause forfeiture on my part of any compensatory time off in lieu of overtime compensation for any overtime hours worked. The State Personnel Department is not responsible for late receipt of applications due to mail service or faxing malfunctions. Signature Date Your name may be removed from an employment register for any disqualifying reason. AN EQUAL OPPORTUNITY EMPLOYER

General Instructions

A SEPARATE APPLICATION

IS REQUIRED FOR EACH

JOB. Do not write in shaded

areas. Complete all parts of

the application. Applications not prop-

erly completed will be returned. Photo-

copied and facsimile applications will

be accepted.

PRINT ALL INFORMATION LEGIBLY

ENTER LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER BELOW List three independent persons, not relatives or present employer, who know you well enough to give information about you. NAME ADDRESS AND PHONE NUMBER EMPLOYER

WORK HISTORY

THIS SECTION MUST BE COMPLETED REGARDLESS OF WHETHER OR NOT A RÉSUMÉ IS ATTACHED. 1. Current or Last Employer

Address

Begin with your PRESENT or most recent employment. List in REVERSE ORDER periods of employment. Each time you changed jobs or your title changed should be listed as a separate period. Describe in detail your duties. (Attach additional sheets if needed.) Providing salary information is optional.

Type of Business

FROM

Month Year

TO

Month Year

Total

Months Worked

Number of Hours

Per Week

Beginning Salary

$ Per

Ending Salary

$ Per

Number/Title of Employees You Supervised

On a Continuing Basis

Name, Title and Telephone Number

of Supervisor

Describe Your Duties in Detail

Reason for Leaving

LAST FOUR D,*,76 OF S2 S(&85,7< NUMBER: Should you need testing accommodations due to a health problem or disability, you must contact the State Personnel Department. Have you ever been involuntarily terminated, discharged, forced to resign, resigned with disciplinary action pending, or resigned in lieu of termination from any job? Yes No

,I \RX DQVZHUHG <HV WR WKH DERYH TXHVWLRQ SURYLGH DQ H[SODQDWLRQ QRWLQJ DQ\ PLWLJDWLQJ RU H[WHQXDWLQJ FLUFXPVWDQFHV LQ WKH VSDFH EHORZ,I QHFHVVDU RX PD\ XVH D separate sheet or sheets and attach to the application. Have you ever been convicted of a misdemeanor or felony crime? (including pleading guilty or nolo contendere, or attending pretrial diversion.) Yes No

,I \RX DQVZHUHG <HV WR WKH DERYH TXHVWLRQ OLVW LQ WKH VSDFH EHORZ DOO SULRU PLVGHPHDQRU DQG IHORQ\ FRQYLFWLRQV DQG DQ\ H[WHQXDWLQJ RU PLWLJDWLQJ FLUFXPVWDQFHV UHJDUGLQJ VXFK FRQYLFWLRQV,I QHFHVVDU RX PD\ XVH D VHSDUDWH VKHHW RU VKHHWV DQG DWWDFK WR DSSOLFDWLRQ Have you ever been known by any other name(s)? Yes es I Yes, what name(s)? NOTE: THE DISCLOSURE OF A CRIMINAL CONVICTION WILL NOT NECESSARILY BE A BAR TO CONSIDERATION FOR EMPLOYMENT, EXCEPT AS REQUIRED BY LAW. ONCE QUALIFIED FOR A POSITION AND PLACED ON A REGISTER, THE EMPLOYING AGENCY MAY THEN DETERMINE IF THE APPLICANT’S DISCLOSED CRIMINAL CONVICTION IS DIRECTLY RELATED TO THE DUTIES FOR THE POSITION BEING CONSIDERED. CRIMINAL HISTORIES WILL BE SUBMITTED TO THE NATIONAL CRIME INFORMATION CENTER (NCIC) FOR VERIFICATION. FAILURE TO DISCLOSE A CONVICTION MAY BE CONSIDERED AS GROUNDS FOR DISQUALIFICATION. FOR THESE REASONS, APPLICANTS SHOULD BE CAREFUL TO DISCLOSE ALL CRIMINAL CONVICTIONS.

2. Employer

Address

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Type of Business

FROM

Month Year

TO

Month Year

Total

Months Worked

Number of Hours

Per Week

Beginning Salary

$ Per

Ending Salary

$ Per

Number/Title of Employees You Supervised

On a Continuing Basis

Name, Title and Telephone Number

of Supervisor

Describe Your Duties in Detail

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Reason for Leaving

5. USING THE ABOVE FORMAT, SHOW OTHER EXPERIENCE BY USING ADDITIONAL SHEETS. LAST FOUR D,*,76 OF S2 S(&85,7< NUMBER: 3. Employer

Address

<RXU 2I FLDO -RE 7LWOH

Type of Business

FROM

Month Year

TO

Month Year

Total

Months Worked

Number of Hours

Per Week

Beginning Salary

$ Per

Ending Salary

$ Per

Number/Title of Employees You Supervised

On a Continuing Basis

Name, Title and Telephone Number

of Supervisor

Describe Your Duties in Detail

(TXLSPHQW <RX 2SHUDWHG

Reason for Leaving

4. Employer

Address

<RXU 2I FLDO -RE 7LWOH

Type of Business

FROM

Month Year

TO

Month Year

Total

Months Worked

Number of Hours

Per Week

Beginning Salary

$ Per

Ending Salary

$ Per

Number/Title of Employees You Supervised

On a Continuing Basis

Name, Title and Telephone Number

of Supervisor

Describe Your Duties in Detail

(TXLSPHQW <RX 2SHUDWHG

Reason for Leaving

COMPLETE THIS SECTION IF YOU ARE CLAIMING VETERAN’S PREFERENCE If you claim Veteran’s Preference, check the type below. Attach copies (which will not be returned) of the required documents to your application to support your claim. 1 Veteran (5 points) - Requires DD214 or document showing dates of service and type of discharge. If this has been submitted previously and is on file with this office, you may disregard this requirement. Note: Must be active duty for other than training purposes. 2 Disabled Veteran (10 points) - Requires DD214 or other document as above and letter of disability from V.A. dated within last 6 months. V.A. letter must be kept updated until register is established or you lose the extra 5 points. 3 Deceased Veteran’s spouse (10 points) - Requires DD214 or other document as above and marriage and death certificates. Cannot be claimed if spouse remarries. 4 Disabled Veteran’s spouse (10 points) - Requires DD214 or other document as above and V.A. letter of disability dated within last 6 months. Cannot be claimed unless still married to disabled veteran who because of this disability is not themselves qualified. 5 Permanently Disabled Veteran (10 points) - Requires DD214 or other document as above indicating veteran is permanently disabled or DD214 or other document and V.A. letter indicating permanent disability.

ENTER ALL N D OF S S NUMBER: - - COMPLETE THIS SECTION IN ORDER TO BE SCHEDULED FOR WRITTEN EXAMS 6 Jacksonville 9 Montgomery 11 Florence 8 Mobile 12 Tusca loosa 14 Troy

notice showing the place and time you are to report for the exam. 13 Huntsville

15 Auburn

5 Friend/Relative

6 Dept. News Bulletin

9 Legislative Representative

10 State Recruiter / Counselor

13 TV/Radio Commercial

14 State Personnel Dept. Website

1 State Career Center

2 Job Announcement Notice

3 Newspaper 7 Rehabilitation Services 11 State Personnel Dept. Information Board 15 Other Website 4 College Placement/Career Office 8 High School Counselor 12 Outreach Program (i.e. Church) 16 Other Where did you learn of this job? (check all that apply) 81 - Northwest Alabama 84 - Jasper/ 87 - East Central Alabama 90 - Montgomery Area 93 - South Central AVAILABILITY

17 Colbert Winfield Area

29 Fayette

38 Lamar

30 Franklin

39 Lauderdale

40 Lawrence 47 Marion

64 Walker

67 Winston

08 Calhoun

09 Chambers

14 Clay

15 Cleburne

19 Coosa

56 Randolph

61 Talladega

62 Tallapoosa

82 - Huntsville/ 85 - Tuscaloosa Area 88 - Southwest Alabama 91 - Phenix City 94 - Dothan Area Decatur Area

36 Jackson

42 Limestone

45 Madison

12 Choctaw

13 Clarke

46 Marengo

65 Washington

48 Marshall

52 Morgan

04 Bibb

32 Greene

33 Hale

54 Pickens

60 Sumter

63 Tuscaloosa

83 - Northeast Alabama 86 - Birmingham Area 89 - Selma/Clanton Area 92 - Mobile Area 95 - Statewide 10 Cherokee 05 Blount

25 Dekalb 22 Cullman

28 Etowah 37 Jefferson

58 Shelby

11 Chilton

24 Dallas

53 Perry

66 Wilcox

59 St. Clair

Alabama

07 Butler

18 Conecuh

01 Autauga

26 Elmore

43 Lowndes

51 Montgomery 20 Covington

21 Crenshaw

27 Escambia

50 Monroe

Troy Area 16 Coffee

03 Barbour 23 Dale

06 Bullock 31 Geneva

41 Lee 34 Henry

44 Macon 35 Houston

55 Pike

57 Russell

02 Baldwin ( You will be

49 Mobile considered for

vacancies through-

out the state.

Relocation may

be necessary)

Birmingham

5 Dothan

,I \RX TXDOLI RX ZLOO UHFHLYH D

Please answer the following questions with care. List in the spaces provided those areas of the state in which you would accept employment. You will be considered for employment only in the locations you indicate. You may choose a combination of up to seven counties and/or regions from the list above. If you list a region, you will be considered available for all counties in that region. The counties in each region are listed alphabetically below the region. You will not be considered for jobs involving overnight travel or shift work unless you so indicate. List the numbers of up to 7 counties and/or regions where you are willing to work Enter the earliest date you will be available to interview for employment. (Your name will not appear on a list of eligibles until this date.) Will you accept work involving overnight travel? Yes No Will you accept temporary work? Yes No

Will you accept part-time work? Yes No

Will you accept conditional work? Yes No

Which shifts are you willing to work? 0. all shifts 1. 1st only 2. 2nd only 3. 3rd only 4. 1st and 2nd only 5. 1st and 3rd only 6. 2nd and 3rd only NOTE: Your name will be placed on inactive status for this class after declining three offers of employment consideration or failing to reply to an agency’s inquiry concerning your availability. Your name may be restored to the active register by written request. Month Day Year

Contact this candidate