PAYROLL'ACTIVITY REPORT FOR REQUEST # 364

PAYROLL INFORMATION
Request Number 364 From BU
Action Regular Appointment ToBU
Name JOHN THOMAS 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 1st
From Shift To Edyc
From Educ To in Lieu
From in Lieu To Total Hourly Rate 16.8631
From Total Hourly Rate 0.0000 To Total Weekly Rate 708.25
From Total Weekly Rate 0.00

PH Approval Approved
, f DepSfttnenfrOf Homeland Security OMB No. 1615-0047; Expires 03/31/07
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 ^ Middle Initial Maiden Name

Address (Street Name and Number) Apt. # Date of Birth (my ith/day/year)
'>6
City - -o State Zip Code Socjefsecumy #
V . - ''• - =~
^ - . ^
1 aftestjjpder penalty of perjury, that 1 am (check one of the following):
Talrra^vaTelhaTfederal law provides for fR^A citizen or national of the United States
ifnprisonment and/or fines for false statements or j ) A Lawful Permanent Resident (Alien #) A
use of false documents in connection with the
O An alien authorized to work until
completion of this form.
(Alien # or Admission #)
Employee's Signature Y ;? / ^/^^ / 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.
Prepared/Translator's Signature Print Name

Address (Street Name and Number, City, State, Zip Code) Date (month/day/year)

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).
List A OR ListB AND ListC
Document title:

Issuing authority:

Document #:

Expiration Date (if any): fO,

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.)
mature oj Print Name

Business or Organization Name
Section 3. Updating and
A.New Name (if applicable)
} Address (Street Name and number, City, State, Zip C Date (month/day/year)
HARTFORD FIRE DEPARTMENT
and signed by employer.
B. Date of Rehire (month/day/year) (if applicable)
HARTFORD, CONN. 06103

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 Title: Document #:
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.
Signature of Employer or Authorized Representative Date (month/day/year)

NOTE: This is the 1991 edition of the Form 1-9 that has been rebranded with a Form 1-9 (Rev. 05/31/05)Y Page 2
current printing date to reflect the recent transition from the INS to DHS and its
components.
 . Employment Application
City of Hartford
Personnel Department
550 Main Street, Ground Floor H R
Hartford, CT 06103 C ™
Office Hours: Mon-Frl 8:30 a.m. - 4:30 p.m. p- c» J:
860-543-8590 (Office) -™~ ~r, '"
860-543-8593 (Job Line) / 860-722-8042 (Fax|S
www.hartford.aov ^'j ix> £"•
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)

(PRINT)
Jo Inn a.
3.
Ha. i STREET ADDRESS STATE ZIP CODE

4.
HOME PHONE NO. WORK PHONE NO. SOCIAL SECURITY NO.

7
- I tO I 8. t ".;•
E-MAIL ADDRESS
DATE OF BIRTH

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

/\ 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 Location Last Year
Completed
12
Diploma/

i
Yes)/ No
Dates Attended

|C, College/University Location Dates Attended Degree/Major Credits

, CT ^0-^3- 5/a- &J a 10

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
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:
^ £}
-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? Yes
If Yes, indicate language and check type and degree of fluency:

Language —==
Speak L....J Readl I Write I I Excellent [ 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: Date
Res _____ Educ ____
Exp ____ Not City Emp
Other
Rev 10/02
 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 Literature / .Arts
scorels 225 (45, average) with

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? Q No 01 Yes

If yes, please explain.
a

ff //1* lo b
/
Sig&arare p Date f
T"11'r-e r-h <cAj AJ> .A-
A
3E_£253L
Position for wluch you are applying Exam #

Page 5 of 5