SOCIAL SECURITY NUMBER

OFFICE USE ONLY

APPROVED

DISAPPROVED

PENDING

BY

REASON

APPLICATION RECRUITMENT AND EXAMINATION

Please fill out completely. Omissions may result in application being rejected. Resumes may NOT be substituted for this application. Type or print clearly. Information provided is confidential and will only be used by authorized personnel. Applicants who are within six (6) months of meeting the education and/or experience qualifications can be approved for the examination pending completion of those requirements.

Position Applied For:

A separate application is required for each classification or position for which application is filed.

Print Name:

LastFirstMiddle

Address:

Number and Street or R.F.D.

CityCountyStateZip Code

Home Phone: ( )Work Phone: ( )

Please check () where you will accept employment.Please check () the sources from which you learned about

this position.

Garrett Prince George’s Newspaper (specify)

Allegany Charles Journal (specify)

Washington Calvert Radio or Television

Frederick St. Mary’s College Recruitment

CarrollAnne Arundel High School Recruitment

Montgomery Queen Anne’s Employment Office

Baltimore City Talbot Bulletin Board

Baltimore County Caroline Heard about from an Employee

Howard Dorchester Interest File

Harford Wicomico Other (specify)

Cecil Somerset

Kent WorcesterPlease check () availability below.

Full-Time Employment Only

Part-Time Employment Only

Full-Time and/or Part-time Employment

Applicants are requested to voluntarily provide this information for statistical purposes only;

however failure to do so will not affect your chances for employment

Male / Race / Ethnic Identification
Female / Birth Date / White (not of Hispanic origin)
African American
Native American
TTY/TTD (410)684-6919 / Hispanic
Special Arrangements and/or accommodations / Asian / Pacific Islander
will be provided upon request / Other

AN EQUAL OPPORTUNITY EMPLOYER

DTS-1 (6-95)

EMPLOYMENT RECORD

1. List all relevant work experience, including experience gained in the armed forces, different jobs held within the

same organization, pertinent volunteer work, and part-time employment.

2. Please list your MOST RECENT work experience FIRST.

3. For some positions, the application may be evaluated for a test score, so please be specific in describing actual tasks

performed.

4. If more space is required, you may attach additional pages to the application. Be sure to put your social security

number on all additional pages.

A / COMPANY NAME / SUPERVISOR’S NAME TELEPHONE NUMBER
ADDRESS / FULL TIME/PART TIME / NUMBER OF HOURS
WORKED PER WEEK / NUMBER OF PERSON’S SUPERVISED
REASON FOR LEAVING
DATE: (MONTH/YEAR)
FROM: TO: / JOB TITLE:
SPECIFIC DUTIES
B / COMPANY NAME / SUPERVISOR’S NAME TELEPHONE NUMBER
ADDRESS / FULL TIME/PART TIME / NUMBER OF HOURS
WORKED PER WEEK / NUMBER OF PERSON’S SUPERVISED
REASON FOR LEAVING
DATE: (MONTH/YEAR)
FROM: TO: / JOB TITLE:
SPECIFIC DUTIES
C / COMPANY NAME / SUPERVISOR’S NAME TELEPHONE NUMBER
ADDRESS / FULL TIME/PART TIME / NUMBER OF HOURS
WORKED PER WEEK / NUMBER OF PERSON’S SUPERVISED
REASON FOR LEAVING
DATE: (MONTH/YEAR)
FROM: TO: / JOB TITLE:
SPECIFIC DUTIES
D / COMPANY NAME / SUPERVISOR’S NAME TELEPHONE NUMBER
ADDRESS / FULL TIME/PART TIME / NUMBER OF HOURS
WORKED PER WEEK / NUMBER OF PERSON’S SUPERVISED
REASON FOR LEAVING
DATE: (MONTH/YEAR)
FROM: TO: / JOB TITLE:
SPECIFIC DUTIES

List any additional information that may help the MDOT evaluate your qualifications for the position for which you are applying, e.g., special skills, computer programs, licenses, certifications, training seminars and workshops, etc.

EDUCATION:

Did you graduate from high school or have you obtained a GED? YesNo Year

Name of High School

Address

If “NO” check the highest grade successfully completed:Below 8 8 9 10 11

NAME OF COLLEGE/UNIVERSITY / NAME OF COLLEGE/UNIVERSITY
ADDRESS / ADDRESS
DATES ATTENDED
FROM: TO: / DATES ATTENDED
FROM: TO:
MAJOR / MAJOR
NUMBER OF CREDIT HOURS
COMPLETED / DEGREE TITLE & YEAR RECEIVED / NUMBER OF CREDIT HOURS
COMPLETED / DEGREE TITLE & YEAR RECEIVED
LIST PERTINENT UNDERGRADUATE COLLEGE
SUBJECTS COMPLETED / SEMESTER
CREDIT HOURS / LIST PERTINENT UNDERGRADUATE COLLEGE
SUBJECTS COMPLETED / SEMESTER
CREDIT HOURS
TRADE OR TECHNICAL / COURSE / COURSE WORK
COMPLETED? / CERTIFICATE AWARDED (TITLE AND DATE)

Drivers License: (You must provide the following information for positions requiring a valid driver’s license.)

Issued by the State of Expiration Date:

License Number Class Birth Date:

Have you had any convictions on misdemeanor or felony criminal offenses other than minor traffic violations? Yes No

If yes, give details below. A conviction is not an automatic disqualification to employment.

LICENSES: If a license, certificate, or other authorization to practice trade or profession is required, complete the following section. All requirements under licensing section of the job specifications must be complied with, and verification submitted with this application form.

TYPE OF LICENSE / LICENSE NUMBER / EXPIRATION DATE / GRANTED BY (LICENSING BOARD)
TYPE OF LICENSE / LICENSE NUMBER / EXPIRATION DATE / GRANTED BY (LICENSING BOARD)
TYPE OF LICENSE / LICENSE NUMBER / EXPIRATION DATE / GRANTED BY (LICENSING BOARD)
TYPE OF LICENSE / LICENSE NUMBER / EXPIRATION DATE / GRANTED BY (LICENSING BOARD)

I certify that all information contained on this application is true and complete. I authorize the Maryland Department of Transportation to contact all sources necessary to verify this information. I understand that any erroneous, misleading or fraudulent information is sufficient grounds for rejection from the examination process, removal from the list of eligibles, withdrawal of an offer of employment or immediate discharge.

Signature of Applicant Date