John Thomas Application

PAYROLL'ACTIVITY REPORT FOR REQUEST # 364 PAYROLL INFORMATION Request Number 364 Action

From BU

Regular Appointment

Name JOHN THOMAS

ToBU

3

From Proaarn

Address

To Progam

Emp_# -

^--~£/'

From Dept

Effective Date 5/5/2008

To Dent

To Date 5/16/2008

Coding Dept Coding Acct

Coding CHKLoc

211P004rTrainrng

Coding Proaam •-•

Coding Pro! #

Tax Exemptions

Payroll Period Weekly

To Class 5101-FIREFIGHTER

From (Bi Meekly Hours 0.00

To (BiMeekly Hours 42.00

From Class

To Shift

From Shift

To Edyc

From Educ

To in Lieu

From in Lieu

To Total Hourly Rate

From Total Hourly Rate 0.0000

1st

16.8631

To Total Weekly Rate 708.25

From Total Weekly Rate 0.00 PH Approval

Approved

,

OMB No. 1615-0047; Expires 03/31/07

f DepSfttnenfrOf Homeland Security V.S.. CitizensKip and Immigration Services

Employment Eligibility Verification

Please read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: ft is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification. To be completed and signed by employee at the time employment begins. Print NamejLast

First

^

Address (Street Name and Number) City V

-

-o

State

Y ;?

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.

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Maiden Name

Apt. #

Date of Birth (my ith/day/year)

Zip Code - ''• - =~

Socjefsecumy #

'>6

^

-

.

1 aftestjjpder penalty of perjury, that 1 am (check one of the following): fR^A citizen or national of the United States j ) A Lawful Permanent Resident (Alien #) A

Talrra^vaTelhaTfederal law provides for ifnprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. Employee's Signature

Middle Initial

O An alien authorized to work until (Alien # or Admission #) Date (monthjday/yeaf) ,

/

C

^^ ' C^^^teP^e /qj^Franslator Certificatida^fTo be completed and signed if Section 1 is preparfd by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Print Name Prepared/Translator's Signature Date (month/day/year)

Address (Street Name and Number, City, State, Zip Code)

Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if any, of tho documents).

OR

List A

ListB

AND

ListC

Document title: Issuing authority: Document #:

fO,

Expiration Date (if any): Document #: Expiration Date (if any):

CERTIFICATION - (attest, under penalty of perjury, that I have examined the documents) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on (month/day/year) *$*)<$']&&' and 'hat to the best of my knowledge the employee is eligible to work in the United States. (State employment agencies may omit the date the employee began employment.) Print Name

mature oj Business or Organization Name

}

and signed by employer.

Section 3. Updating and A.New Name (if applicable)

Date (month/day/year)

Address (Street Name and number, City, State, Zip C

HARTFORD FIRE DEPARTMENT HARTFORD, CONN.

06103

B. Date of Rehire (month/day/year) (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility. Expiration Date (if any): Document #: Document Title: I attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and If the employee presented documents), the documents) I have examined appear to be genuine and to relate to the Individual. Date (month/day/year) Signature of Employer or Authorized Representative NOTE: This is the 1991 edition of the Form 1-9 that has been rebranded with a current printing date to reflect the recent transition from the INS to DHS and its components.

Form 1-9 (Rev. 05/31/05)Y Page 2

^

. Employment Application City of Hartford Personnel Department 550 Main Street, Ground Floor Hartford, CT 06103

H C

R ™

Office Hours: Mon-Frl 8:30 a.m. - 4:30 p.m. p860-543-8590 (Office) -™~ 860-543-8593 (Job Line) / 860-722-8042 (Fax|S

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www.hartford.aov

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In compliance with the Freedom of Information Act, most of the information In this application may be considered a matter of public record. Please answer all qu&Hons fully'. and accurately. Applications may be rejected or receive lower ratings If answers are Incomplete, vague or evasive. Your statements may be brief but should InclutfeJall Information relevant to the qualifications of the position for which you are applying. The completion of the attached Affirmative Action Data Sheet is voluntary but completion of the attached question regarding criminal conviction Is mandatory. The City of Hartford Is an Equal Opportunity Employer.

i. FnteTi^nrfe

JOB APPLYING FOR (USJ TITLE ON JOB ANNOUNCEMENT)

a.

Jo Inn

(PRINT)

3. Ha. i STREET ADDRESS

STATE

ZIP CODE

4. HOME PHONE NO.

7

-

9.

SOCIAL SECURITY NO.

WORK PHONE NO.

I tO I

8.

t ".;•

E-MAIL ADDRESS

DATE OF BIRTH

Are you now or have you ever been employed by the City of Hartford/ Hartford Board of Education or Hartford Public Library? If yes, please indicate the employer, position and date(s) of employment

Yes

t

/\ Eifploye

Posfton

Dates oMmployment

10. Are you a U.S. Citizen or authorized to work in the U.S.?

Yes

No

(Please note that if you are hired, you will be required to provide proof of U.S. Citizenship or authorization to work in the U.S. - U.S. citzenship is required for Police Officer positions.)

11. EDUCATION A. Give highest grade completed if you didjigi attend high school. B. High School

Hi1

Last Year Completed 12

Location

|C, College/University

Dates Attended

Location

, CT

^0-^3-

Diploma/

i

Yes)/ No

Degree/Major

5/a- &J

D. SPECIALIZED TRAINING/ACTIVITIES List specialized training and extra-curricular activities

M

Some Veterans may be eligible for special preference - check with the Personnel Department.

Page 1 of 5

Dates Attended

Credits

a 10

12. SPECIAL QUALIFICATIONS AND SKILLS A. List licenses, (include driver's license or commercial driver's license A, B or C) or certifications which you possess for any type of work. Also list the state or other licensing authority which, granted it and applicable operator numbers and Jexpira expiration dates:

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^

-W B. List any special skills, machines and equipment which you can operate (include typing speed if appropriate) which may qualify you for the position for which you are applying:

"5r

C. Give any special qualifications not covered elsewhere in this application, such as (1) your publications; (2) membership in professional organizations; (3) honors and awards received:

rl

D. List all computer programs with which^you are proficient; MS Word, MS Access, Excel, etc.;

_M£_

E Can you speak, read or write any language other than English? If Yes, indicate language and check type and degree of fluency: Language —== Speak L....J Readl I Write I

I

Excellent [

Yes

jGood[

I Fairi

1

14, REFERENCES! List below three individuals who can describe your qualifications for this position, preferably supervisors, co-workers, professors, colleagues, etc. Name and Job Title: Company/Agency Name: Complete Address: I53ff V Phone:

Name and Job Title: Company/Agency Name: Complete Address: Phone:

(#>r> )

Name and Job Title: _ Company/Agency Name: Complete Address: Phone: (

CERTIFICATION: certify that all information provided on or in connection with this application is true, complete, and correct to the best of my knowledge and belief and is made in good faith. I understand that the information is subject to vsrfication by the City of Hartford and that incomplete, false, misleading or inaccurate information may result in the rejection of this application and that false information may result in my dismissal if employed. I also give my consent to the former employers, schools and references identified in this application to release all information concerning me to the City of Hartford. I also hereby release the City of Hartford as well as each former employer, school and reference identified in this application from any and all claims and liabilities that may arise from disclosure of information concerning me to the City of Hartford. I also give my permission for the City of Hartford to investigate my personal history through, among other things, review of criminal history records, motor vehicle records and other records as may be appropriate. I hereby give my consent to the Connecticut Department of Motor Vehicles, the Connecticut Department of Public Safety, the Connecticut Department of C he Connecticut Department of Children and Families and the Federal Bureau of Investigation to release records concerning me to the Ity of Hartford. I understand that the City's acceptance of this application does not constitute or imply an employment agreement. I agree that, if I am employed, I will abide by all City policies, procedures, directives and rules.

^•"APPLICANT'S SIGNATURE

For Personnel Use: Do not write in this space

Vet

Dis. Vet

Reviewed by: Res Exp Other

Rev 10/02

_____ ____

Educ ____ Not City Emp

Date

fftff 'or . DEPARTMENT OF GENERAL EDUCATIO

OFFICIAL REPORT

I§LTS

fhis Gertifhss that th© following High School Level Examination results were achieved by;

tfb'hally Connecticut since March, 1967 scorels 225 (45, average) with

Literature / .Arts

cote Average :

BASED ON THE ABOVE TJST MBERli

©ED/

;TRAT

QUESTION REGARDING CONVICTIONS (Question must be completed)

Please note the following definitions that relate to your response to this question. "Conviction", for the purpose of this application, means a final judgment or verdict of guilty, a plea of guilty, or a plea of nolo contendere, in any state or federal court, regardless of whether an appeal is pending or could be taken. "Conviction", for the purpose of this application, does not include a final judgment or verdict that has been expunged by pardon, reversed, set aside or otherwise rendered invalid. Further, you are not required to disclose any arrest(s). criminal charges(s) or convictionCs) the records(s) of which have been erased under law Such records can include records of a finding of delinquency or that a child was a member of a family with service needs, adjudication of youthful offender status, criminal charges dismissed or nolled, or charges for which a person is found not guilty or a conviction later resulting in an absolute pardon. Further, any person whose criminal records have been erased is deemed under law never to have been arrested with respect to such erased proceedings and may so swear under oath. A history of criminal conviction(s) will not necessarily bar consideration of employment. Factors such as the time, seriousness and nature of the offense, rehabilitation, as well as the nature of the position for which you are applying, will be taken into account. Should you have any questions about answering questions on this application, or your rights concerning erased records, please contact the Personnel Department. a Have you ever been convicted of a crime? If yes, please explain.

Q No

01 Yes

a

ff //1* lo b Sig&arare

p

T"11'r-e r-h .A-

A Position for wluch you are applying

Date

/

f

3E_£253L Exam #

Page 5 of 5