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Iowa Application for State Employment Page 5
Iowa Application for State Employment
CFN 552-0072 R 3/11 5
Special Requirements or Qualifications
Some jobs have special requirements. They will be found on the vacancy announcement and/or the job class description in the
section titled “Competencies Required,” or “Selective Certification.” Write needed information below.
Experience Dates
List all languages, including American Sign Language, Braille and Tactile Braille, in addition to English, that you speak, read, and/or write fluently
. For each language
listed, indicate S for Speak, R for Read, or W for Write fluently. You will be required to demonstrate your skill in all areas and languages you indicate fluency.
If you possess a license or certificate to practice a trade or profession, complete the following:
Name of Trade or Profession:
License Number:
Issued by:
Specialty: Expiration Date:
If a teacher’s certificate, Endorsement Numbers:
Approval Numbers:
Veterans Points
Upon request, veterans points shall be applied to honorably discharged veterans as defined in Iowa Code Chapter 35C. Former
members of the reserve forces or National Guard who served at least 20 years after January 28, 1973, are eligible. Reserve
forces or National Guard veterans who were activated for federal duty, other than training, for a minimum of 90 days and were
discharged under honorable conditions or retired under Title 10, United States Code, are eligible. Veterans with a service-
connected disability, a Purple Heart, or who are receiving disability compensation or pension through the U.S. Veterans
Administration, may also request veterans points. Proof of disability from the Veterans Administration must be submitted and
updated every two years. A copy of your certified DD214 must be submitted for proof of service.
Veterans Points: Do you want to be considered for veterans points Yes No
If yes, you must provide proof of service by submitting a photocopy of your DD-214 form.
Read the Following before Signing
I certify that this application (and any copy or facsimile of same) and applicant survey contains no willful misrepresentation and
that the information is true and complete to the best of my knowledge. I understand that:
Should an investigation at any time disclose otherwise, my application may be rejected, my name may be removed from
consideration for employment, I may be discharged from employment with the State of Iowa, and I may be disqualified from
applying for any other position under the jurisdiction of the Iowa Department of Administrative Services – Human Resources
Information on this application and any documents submitted to be included with this application may, in compliance with
Iowa Code Chapter 22, become public record and may be made available to the public upon request. Only information
deemed confidential in accordance with applicable statutes may be withheld from public disclosure.
Background investigations may be conducted as part of this application for employment. These include, but are not limited
to, inquiries relating to driving records for jobs requiring travel, inquiries about convictions where job related, and any other
investigations deemed necessary and relevant by the employer.
The State of Iowa complies with the federal law requiring pre-employment, random, post-accident, reasonable suspicion, and
return to duty drug and alcohol testing for all persons in positions requiring a Commercial Driver's License.
By signing this Application for State Employment, I am consenting to any reasonable inquiry that may be necessary to
verify the information I have provided on this form or that I may otherwise provide in conjunction with my Application
for State Employment.
Signature: Date:
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