Application for Employment Form - Oklahoma

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State of Oklahoma
EMPLOYMENT APPLICATION
Office of Personnel Management
Jim Thorpe Memorial Office Building, Room B-22
2101 North Lincoln Boulevard Oklahoma City, OK 73105 OPM website: www.opm.state.ok.us
(405) 521-2171 (405) 521-6314 - TDD Number (You must have a TDD machine to use the TDD number.)
Please print clearly or type
Please read instructions on page 2 before completing the application
Social Security Number: ____________________________ Date of Application:____________________________
Name: __________________________________________________________________________________________
Last First Middle
Mailing Address: __________________________________________________________________________________
Street Address, Apt # City State Zip Code
County: _______
(Codes on page 2)
E-mail address ___________________________________________________
Evening Telephone:_____________________________ Day Telephone: _____________________________
(Include area code)
(Include area code)
JOB OR JOB FAMILY DESIRED:______________________________________________________
Indicate the conditions under which you will accept employment (Yes or No - If blank, YES is assumed)
Full-time: ___________ Part-time: ____________ Shift work: ____________
Travel: ____________ (Travel may include regular overnight or across town assignments)
Are you at least 21 years of age?_____ (Yes or No) (Will be used only where age is an approved, bonafide job requirement.)
List the county codes (listed on page 2) for which you wish to be considered for employment. If none are indicated it is assumed
you are willing to work anywhere in the state.
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____
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For Office Use Only
JFD Code A/R Code Score Initial/Date JFD Code A/R Code Score Initial/Date
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The Office of Personnel Management will remove this section
Voluntary Applicant Survey - The information requested will be used to assist state agencies in complying with state and federal record keeping and reporting
requirements. It may be made available to employing agencies when they exercise state laws authorizing affirmative action in hiring. Please provide accurate
information. Your cooperation is important and appreciated. For affirmative action purposes, state law requires any person who lists American Indian as
his/her race or ethnic group to verify tribal affiliation by providing a certificate of Degree of Indian Blood from the U.S. Department of Interior, Bureau of Indian
Affairs, or by providing the name and address of tribal officials who can verify tribal affiliation. Do NOT turn this verification in with this employment application.
It should be turned in to the hiring agency within thirty days of appointment.
Social Security Number:___________________ Sex:______ (M or F)
Race or Ethnic Group (Check only one)
1._____ Black (not of Hispanic origin)
2._____ Asian or Pacific Islander
3._____ American Indian or Alaskan Native
4. _____ Hispanic (Mexican, Puerto Rican, Cuban
Central or South American or other Spanish
culture or origin, regardless of race)
5. _____ White (not of Hispanic origin)
The State of Oklahoma is an Equal Opportunity Em ployer
OPM-4 (12/21/04) Page 1 of 4
Page 1/4
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Application for Employment Form - Oklahoma PDF

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