ࡱ> %` 8qbjbj"x"x .@@1000Dt,D8 PPPP&T,$h70є7PPTmmmP0PmmmT0mP, @-:m j0m5( m0m /՟m=///77]///DDD$<hD$;DDDhDDDD State of Maryland(OFFICE USE ONLY) MAIL APPLICATION TO THE ADDRESS INDICATED ON THE JOB ANNOUNCEMENT For Job Announcements visit:  HYPERLINK "http://www.dbm.maryland.gov" www.dbm.maryland.gov or call 410-767-4850 Class Code APPR. _______ DISAPPR. _______ BY _____ Reason: ________________________________ _______________________________________ Pending Code: SOCIAL SECURITY NUMBER:   FORMTEXT      PRINT OR TYPE ALL INFORMATIONApplying For:Job Title:  FORMTEXT      Announcement #:  FORMTEXT       (A separate application is required for each job title unless otherwise indicated.)Name and Contact Information:Name: FORMTEXT       FORMTEXT       FORMTEXT   Last FirstMIAddress:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT       Street City CountyStateZip CodeHome Phone:  FORMTEXT       Work Phone: FORMTEXT      E-mail: FORMTEXT      Education and Training:Do you have a high school diploma or GED?Yes  FORMCHECKBOX No  FORMCHECKBOX If not, what is the highest grade that you completed?  FORMTEXT   School: FORMTEXT      Address (City, State): FORMTEXT      Dates attended:  FORMTEXT      - FORMTEXT      Major course of study: FORMTEXT      FromToCOLLEGE AND GRADUATE SCHOOL EDUCATION Name/Location of School(s)Dates AttendedMajor# of Credits CompletedType of DegreeDegree Earned? (Yes or No) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT    SPECIALIZED TRAINING OR CLASSES RELEVANT TO THE JOB Title of Program/Course(s)Company/SchoolDates Attended# of Credits EarnedDiploma/Certificate Received? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT      MS-100 REV. 3/10 STATE OF MARYLAND  AN EQUAL OPPORTUNITY WORK EXPERIENCE:  Job Number 1: (Current or Most Recent)Name of Employer:Employer s Address (Street, City, State, Zip Code): FORMTEXT       FORMTEXT      Type of Business:Supervisor s Name and Phone Number: FORMTEXT       FORMTEXT      Your Job Title:Do you supervise other employees? Job Titles of Those You Supervise: FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  How many?  FORMTEXT       FORMTEXT      Dates of Employment (From: Month/Day/Year To: Month/Day/Year):Is your position considered full-time? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      How many hours do you work per week?  FORMTEXT    Job Duties:  FORMTEXT      Reason For Leaving:  FORMTEXT       Job Number 2:Name of Employer:Employer s Address (Street, City, State, Zip Code): FORMTEXT       FORMTEXT      Type of Business:Supervisor s Name and Phone Number: FORMTEXT       FORMTEXT      Your Job Title:Did you supervise other employees? Job Titles of Those You Supervised: FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  How many?  FORMTEXT       FORMTEXT      Dates of Employment (From: Month/Day/Year To: Month/Day/Year):Was your position considered full-time? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      How many hours did you work per week?  FORMTEXT    Job Duties:  FORMTEXT      Reason For Leaving:  FORMTEXT       Job Number 3:Name of Employer:Employer s Address (Street, City, State, Zip Code): FORMTEXT       FORMTEXT      Type of Business:Supervisor s Name and Phone Number: FORMTEXT       FORMTEXT      Your Job Title:Did you supervise other employees? Job Titles of Those You Supervised: FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  How many?  FORMTEXT       FORMTEXT      Dates of Employment (From: Month/Day/Year To: Month/Day/Year):Was your position considered full-time? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      How many hours did you work per week?  FORMTEXT    Job Duties:  FORMTEXT      Reason For Leaving:  FORMTEXT       ELIGIBILITY FOR VETERANS CREDIT  Job Number 4:Name of Employer:Employer s Address (Street, City, State, Zip Code): FORMTEXT       FORMTEXT      Type of Business:Supervisor s Name and Phone Number: FORMTEXT       FORMTEXT      Your Job Title:Did you supervise other employees? Job Titles of Those You Supervised: FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  How many?  FORMTEXT       FORMTEXT      Dates of Employment (From: Month/Day/Year To: Month/Day/Year):Was your position considered full-time? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      How many hours did you work per week?  FORMTEXT    Job Duties:  FORMTEXT      Reason For Leaving:  FORMTEXT       Job Number 5:Name of Employer:Employer s Address (Street, City, State, Zip Code): FORMTEXT       FORMTEXT      Type of Business:Supervisor s Name and Phone Number: FORMTEXT       FORMTEXT      Your Job Title:Did you supervise other employees? Job Titles of Those You Supervised: FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  How many?  FORMTEXT       FORMTEXT      Dates of Employment (From: Month/Day/Year To: Month/Day/Year):Was your position considered full-time? Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      How many hours did you work per week?  FORMTEXT    Job Duties:  FORMTEXT      Reason For Leaving:  FORMTEXT       Are you fluent in a language other than English? (if required for the job for which you are applying) Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, please list:  FORMTEXT        UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100. This provision does not apply to applicants for law enforcement positions pursuant to Labor and Employment Article, Section 3-702 (b) Annotated Code of Maryland. Have you ever been convicted of any violation of law other than a minor traffic violation? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, give the date, place of conviction, charge and disposition of each case. Note: A conviction record will not necessarily bar you from employment. (Please write this information on a separate sheet of paper and attach it to this application.) DATE: __________________________ SIGNATURE OF APPLICANT: _________________________________________________ In which counties will you accept employment? Please check the box on the left if you will work in all of the counties in that row, OR, circle individual counties of interest.How did you find out about this recruitment? Check the correct box and add information such as the name of the publication or site.OPSB Website FORMCHECKBOX 10  FORMCHECKBOX GARRETT - 11, ALLEGANY - 12, WASHINGTON -13Other Website  FORMTEXT       FORMCHECKBOX 20  FORMCHECKBOX FREDERICK - 21, CARROLL - 22, MONTGOMERY - 23Newspaper ad,&'(*+  I L ϴϤweYYIjh4CJOJQJU^Jh4CJOJQJ^J#h40JB*CJOJQJ^Jph.jh4B*CJOJQJU^Jph(jh4B*CJOJQJU^Jphh4B*CJOJQJ^Jph!h4CJOJQJ^JmHnHuh4OJQJ^Jh4CJOJQJ^Jh45CJ4OJQJ^J-jh45CJ4OJQJU^JmHnHu&$$0&@#$/If]a$$0&@#$/If]$Ifc6q&'()*PG=,$$If]^a$ $If] $$Ifa$kd$$Ifl4[FBc`'`.! 0L,    4 laf4p*+,opqrPGGGGGGG $$Ifa$kd=$$Ifl4[FBc`' ! 0L,    4 laf4p   ! 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laf4n@p@@@@8A\AbYSSSS$If $$Ifa$kd$$Ifl4\d#&P \ 0+4 laf4@@@AAA&A(A*A4A6A8A:AVAXAZAdAfAAAAB@@@.@0@2@<@>@@@ĴСvcaдN%jh4CJOJQJU^JU%jh4CJOJQJU^J%jDh4CJOJQJU^J.jh4CJOJPJQJU^JmHnHu%jh4CJOJQJU^Jjh4CJOJQJU^Jh4CJOJQJ^Jh4CJOJQJ^Jjh4CJOJQJU^J%jh4CJOJQJU^J\A^AAAAD@h@OF@@@@$If $$Ifa$kd֢$$Ifl4hrd#& \ 0+4 laf4 paper name  FORMTEXT        FORMCHECKBOX 30  FORMCHECKBOX BALTIMORE CITY - 31, BALTIMORE COUNTY - 32, HOWARD - 33State Personnel Office location  FORMTEXT        FORMCHECKBOX 40  FORMCHECKBOX HARFORD - 41, CECIL - 42, KENT - 43DLLR Job Service location  FORMTEXT        FORMCHECKBOX 50  FORMCHECKBOX PRINCE GEORGE S - 51, CHARLES - 52, CALVERT - 53, ST. MARY S - 54Job Fair  FORMTEXT        FORMCHECKBOX 60  FORMCHECKBOX ANNE ARUNDEL - 61, QUEEN ANNE S - 62, TALBOT - 63, CAROLINE - 64Other Media  FORMTEXT       FORMCHECKBOX 70  FORMCHECKBOX DORCHESTER - 71, WICOMICO - 72, SOMERSET - 73, WORCESTER - 74Other  FORMTEXT       FORMCHECKBOX  AVAILABLE FOR EMPLOYMENT WHICH IS:  FORMCHECKBOX Full-time  FORMCHECKBOX Part-time  FORMCHECKBOX Temporary  FORMCHECKBOX Contractual Applications must be received by the Office of Personnel Services and Benefits (or the recruiting agency) by either the close of business on the closing date, or postmarked by the closing date, as specified on the job announcement for which you are applying. A receipt will be mailed if a self-addressed, stamped envelope is attached. NOTIFY THE OFFICE OF PERSONNEL SERVICES AND BENEFITS IN WRITING OF A CHANGE IN NAME, ADDRESS OR TELEPHONE NUMBER. YOU MUST BE LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES UNDER THE UNITED STATES IMMIGRATION REFORM AND CONTROL ACT OF 1986. YOU MUST MEET ALL OF THE QUALIFICATIONS TO BE ELIGIBLE FOR APPOINTMENT. VERIFICATION WILL BE COMPLETED BY THE APPOINTING AUTHORITY. YOU MAY BE TESTED FOR ILLEGAL DRUG USE. IF SELECTED FOR A POSITION IN THE SKILLED OR PROFESSIONAL SERVICE, YOU MAY BE GIVEN A MEDICAL EXAMINATION TO DETERMINE YOUR ABILITY TO PERFORM JOB-RELATED FUNCTIONS. I hereby affirm that this application contains no willful misrepresentation or falsifications and that this information given by me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any misrepresentation or falsification, my application will be disapproved, my name removed from the eligible list, and that I will not be certified for employment in any position under the jurisdiction of the Department of Budget & Management. I am aware that a false statement is punishable under law by fine or imprisonment or both. DATE: _____________________SIGNATURE OF APPLICANT: _______________________________________________________________-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Remove this section of the application prior to the interview process.) TO FURTHER ITS COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT, THE STATE OF MARYLAND REQUESTS APPLICANTS TO PROVIDE, VOLUNTARILY, THE FOLLOWING INFORMATION. THIS INFORMATION WILL BE USED FOR STATISTICAL PURPOSES ONLY BY AUTHORIZED PERSONNEL. BIRTH DATE: _____________ MALE  FORMCHECKBOX  FEMALE  FORMCHECKBOX  ARE YOU A U.S. CITIZEN OR LEGAL ALIEN? YES  FORMCHECKBOX  NO  FORMCHECKBOX  Month/Day/YearRACE/ETHNIC IDENTIFICATION  PLEASE CHECK ALL THAT APPLY Are you of Hispanic or Latino origin? Yes  FORMCHECKBOX  No  FORMCHECKBOX  (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) Select one or more of the following racial categories: 1.  FORMCHECKBOX  American Indian or Alaska Native (A person having origins in any of the original peoples of North or South America, including Central America, and who maintains tribal affiliations or community attachment.)2.  FORMCHECKBOX  Asian (A person having origin 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.)3.  FORMCHECKBOX  Black or African American (A person having origins in any of the black racial groups of Africa.)4.  FORMCHECKBOX  Native Hawaiian or other Pacific Islander (A person having origins in the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)5.  FORMCHECKBOX  White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)STATE OF MARYLAND  AN EQUAL OPPORTUNITY EMPLOYER List below, beginning with your most recent position, all of your work experience, including military service and all volunteer activities. Attach additional 8 1/2" x 11 sheets of paper if necessary. If your title and duties changed in the course of your service in any one organization, indicate such changes clearly and as separate employment. Please do not submit a resume in lieu of completing this portion of the application. Be sure that the information included in this section demonstrates that you meet the experience qualifications for the job for which you are applying. Please submit a copy of any relevant professional or trade licenses or certificates with this application. For positions requiring a driver s license, please attach a copy of your license or write on a separate sheet of paper your driver s license number, class, state of issuance and expiration date. This application is part of the examination process. Please read the minimum qualifications section of the job announcement before completing this application. You must meet all of the qualifications to be considered. A copy (not an original) of your proof of eligibility (DD 214) for Veterans Credit must be in this office and completely verified before Veterans Credit will be approved. Proof will only need to be submitted once. Permanent State employees do not need to submit proof of eligibility for Veterans Credit. After a test notice is received, applicants with disabilities who require accommodations should contact the Office of Personnel Services and Benefits at (410) 767-4921, or Toll Free: 1 (800) 705-3493. 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