Fill and Sign the Utah State Courts Form

Name: __________________________________________________________ Address: ________________________________________________________ Home Phone: ___________________ City, State, Zip: ___________________________________________________ Business Phone: _________________ Other names used: ___________________________________________________________________________ Please read the following instructions carefully before filling out your application . All requested information must be furnished. The information that you give will be used to determine your qualifications for employment. It is important that you answer all questions fully and accurately, including your original signature. Failure to do so will result in the rejection of your application for consideration. Position for which you are applying: __________________________________________________________ Check the districts in which you are willing to accept employment. (You will not be considered for districts NOT checked).  All Locations  Court Administration, Appellate & Supreme Courts..............................................[Salt Lake City]  First District.............................................................................[Box Elder, Cache, Rich Counties]  Second District..........................................................................[Davis, Weber, Morgan Counties]  Third District.......................................................................[Salt Lake, Summit, Tooele Counties]  Fourth District.................................................................[Juab, Millard, Utah, Wasatch Counties]  Fifth District..........................................................................[Beaver, Iron, Washington Counties]  Sixth District..........................................[Garfield, Kane, Piute, Sanpete, Sevier, Wayne Counties]  Seventh District..........................................................[Carbon, Emery, Grand, San Juan Counties]  Eighth District.....................................................................[Daggett, Duchesne, Uintah Counties] Are you at least 18 years of age?  Yes  No Can you provide documentation verifying your right to work in the United States?  Yes  No Are you related to anyone who works for the Utah State Courts?  Yes  No Provide name(s) and relationship(s):_____________________________________________________ Do you have a valid Drivers License?  No  Yes DL#_________________________State:_______ Have you ever been convicted (as an adult) of a misdemeanor or felony that has not been expunged from your record?  No  Yes Please explain: _____________________________________________________ Have you graduated from High School  Yes  No If not a high school, specify GED or other certificate: _______________________________________________ List languages you speak, read, and write other than English: __________________________________________ Page 1 of 4Utah State Courts Scott M Matheson Courthouse 450 South State P.O. Box 140241 Salt Lake City, Utah 84114-0241 (801) 578 3800 APPLIC ATION FOR EMPLOYMENT EDUCATION High school and post high school education (colleges, universities, vocation or trade schools, etc.) You must submit a copy of your transcript with this application if it is specified on the job announcement. Failure to do so will result in the rejection of your application. All paper submitted become the property of the courts. Name and location of school Semester Hrs Completed Quarter Hrs Completed Did you Graduate? Graduate? Degree Awarded Major Course of Study List professional or trade licenses, certificates or registrations: _________________________________________________________________________________________ EXPERIENCE Take time to fill in this section carefully and completely. Answers given in this section may be verified with former employers. Start with your present or most recent position and work backwards. If more space is necessary for listing your experience, use a separate sheet of paper. Resumes may be attached, but YOU MAY NOT USE A RESUME AS A SUBSTITUTE FOR FULLY COMPLETING THIS SECTION. Position Title: Dates of Employment (month & year): From: To: Supervisor: Hours per week: Salary: Employer (company) name and address: Your duties: Reason for leaving: Position Title: Dates of Employment (month & year): From: To: Supervisor: Hours per week: Salary: Employer (company) name and address: Your duties: Reason for leaving: Position Title: Dates of Employment (month & year): From: To: Supervisor: Hours per week: Salary: Employer (company) name and address: Your duties: Reason for leaving: Position Title: Dates of Employment (month & year): From: To: Supervisor: Hours per week: Salary: Employer (company) name and address: Your duties: Reason for leaving: Position Title: Dates of Employment (month & year): From: To: Supervisor: Hours per week: Salary: Position Title: Dates of Employment (month & year): From: To: Supervisor: Hours per week: Salary: Employer (company) name and address: Your duties: Reason for leaving: REFERENCES Please list the names, addresses, and telephone numbers of three (3) individuals who are not related to you, but either supervised you or are associated with you professionally. Full Name Business or Home Address Occupation/Title & Relationship Telephone Number VETERAN’S PREFERENCE If you are claiming veteran’s preference, with the exception of disabled veterans, you must submit a photocopy of your discharge showing the dates of service. If you are a veteran claiming disability, you must also submit a letter of verification dated within the last 90 days. Do you claim Veteran’s Preference? If yes, ‘X’ one of the following:  Yes  No  1. As a war veteran.  2. As an unmarried surviving spouse of a veteran. Do you claim Disabled Veteran’s Preference? If yes, ‘X’ one of the following:  Yes  No  1. As a war veteran.  2. As a spouse of a disabled veteran not gainfully employed due to military related disability.  3. As an unmarried surviving spouse of a disabled veteran. CERTIFICATION AND RELEASE STATEMENT Be careful that you have answered all questions on your application correctly and considered all statements fully so that your eligibility can be decided on all the facts. Sign your name below in ink. The information I have given on or attached to this application is true and correct to the best of my knowledge. Having made application for employment with the Utah State Court system, I hereby authorize the courts to conduct a thorough background check including but not limited to references, employments record, convictions and criminal record. I understand that such background checks will only be made upon final selection for hire, and that all information will be kept confidential and released only to authorized individuals. I also understand that any falsification of data on my part will result in disqualification from further consideration or result in termination. I hereby release the courts from any civil or criminal liability arising from my background check. ___________________________________________________________________________________ Signature of Applicant Date Page 3 of 4 THE UTAH STATE COURTS ARE EQUAL OPPORTUNITY EMPLOYERS Appointments are made without regard to sex, age, race, creed, religion, national origin, ancestry, marital status, disability, or other non-job related criteria. The Courts believe in equal opportunity principles. Consequently, we attempt to track our applicant flow for every recruitment. While your participation is entirely voluntary, your cooperation in providing this information is greatly appreciated. Please fill out this sheet completely. DO NOT sign your name. This sheet will be removed from your application upon receipt. The information you provide is confidential and will not be used in the consideration of your application. Position applied for: ________________________________ Date: _____________________________________________ Sex Age Veteran’s Status  Male  39 or less  Viet Nam Era Veteran  Female  40 and over  Disabled Veteran Ethnic Group:  Asian/Pacific Islander  Black (not of hispanic origin)  Hispanic  Native American/Alaskan Native  White (not of hispanic origin)  Other (please specify) Page 4 of 4