Form JD-AP-187 "Certificate of Employability Application - Cssd" - Connecticut

What Is Form JD-AP-187?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2019;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-AP-187 by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

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Download Form JD-AP-187 "Certificate of Employability Application - Cssd" - Connecticut

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CERTIFICATE OF EMPLOYABILITY
STATE OF CONNECTICUT
APPLICATION - CSSD
JUDICIAL BRANCH
JD-AP-187 Rev. 2-19
COURT SUPPORT SERVICES DIVISION
C.G.S. § 54-130e
Instructions to applicant:
ADA NOTICE
Fill out this application and return it with the other required documents to the
The Judicial Branch of the State of Connecticut complies with the
CSSD Certificate Review Unit. See Page 7 of this application for detailed
Americans with Disabilities Act (ADA). If you need a reasonable
instructions on how to fill out the application and where to send it.
accommodation in accordance with the ADA, contact a court clerk
or an ADA contact person listed at www.jud.ct.gov/ADA.
Application for Certificate of Employability
Section 1: Applicant Information
Last name
First name
Middle name
Date of birth
Social security number
Place of birth
Gender
Address (Number and street)
Apartment number/floor
City
State
Zip code
Home phone number
Business phone number
Cell phone number
E-mail address
Section 2: Family Information
Please list all members of your household (anyone who lives with you) below:
Name
Age
Relationship to you
1.
2.
3.
4.
5.
How long have you lived at your current address?
Current marital status?
Single
Married
Divorced
Separated
Widow
Widower
Civil union
Current spouse/partner's name:
Section 3: Alias and Other Names
State, in full, every other name by which you have been known, including the reason for your use of another name, and the dates during
which you were so known (for example, include your maiden name, name by a former marriage, aliases, and nicknames).
1.
2.
3.
Section 4: Previous Application History
Have you applied for a Certificate of Employability or Provisional Pardon in the past?
Yes
No
If yes, please state the month(s) and year(s) you applied:
Section 5: Citizenship Information
Are you a citizen of the United States of America?
Yes
No
If you answered no, country of citizenship:
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(Page 1 of 7)
CERTIFICATE OF EMPLOYABILITY
STATE OF CONNECTICUT
APPLICATION - CSSD
JUDICIAL BRANCH
JD-AP-187 Rev. 2-19
COURT SUPPORT SERVICES DIVISION
C.G.S. § 54-130e
Instructions to applicant:
ADA NOTICE
Fill out this application and return it with the other required documents to the
The Judicial Branch of the State of Connecticut complies with the
CSSD Certificate Review Unit. See Page 7 of this application for detailed
Americans with Disabilities Act (ADA). If you need a reasonable
instructions on how to fill out the application and where to send it.
accommodation in accordance with the ADA, contact a court clerk
or an ADA contact person listed at www.jud.ct.gov/ADA.
Application for Certificate of Employability
Section 1: Applicant Information
Last name
First name
Middle name
Date of birth
Social security number
Place of birth
Gender
Address (Number and street)
Apartment number/floor
City
State
Zip code
Home phone number
Business phone number
Cell phone number
E-mail address
Section 2: Family Information
Please list all members of your household (anyone who lives with you) below:
Name
Age
Relationship to you
1.
2.
3.
4.
5.
How long have you lived at your current address?
Current marital status?
Single
Married
Divorced
Separated
Widow
Widower
Civil union
Current spouse/partner's name:
Section 3: Alias and Other Names
State, in full, every other name by which you have been known, including the reason for your use of another name, and the dates during
which you were so known (for example, include your maiden name, name by a former marriage, aliases, and nicknames).
1.
2.
3.
Section 4: Previous Application History
Have you applied for a Certificate of Employability or Provisional Pardon in the past?
Yes
No
If yes, please state the month(s) and year(s) you applied:
Section 5: Citizenship Information
Are you a citizen of the United States of America?
Yes
No
If you answered no, country of citizenship:
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(Page 1 of 7)
Section 6: Education Background/Special Training
Please check the highest grade you finished:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24+
Please list any education or other special training you have gotten or are currently getting. Include the school name, dates that you went
there, degrees that you earned, and any honors that you got. If you went to training, list the type of training and the agency that provided the
training. You should attach a copy of any certificates, diplomas, or transcripts that you got to this application.
Section 7: Employment History
List your jobs and employers for the last 5 years or since you left school, whichever period is less. Do not leave out or skip any jobs. Start
with the job that you have now or your most recent job and work back.
Dates (month & year)
Job/position
Employer name/address/phone number
Supervisor
1.
2.
3.
4.
5.
6.
Licenses/certifications held
Type of license
Licensing agency
License number
Date issued
Expires
1.
2.
3.
Section 8: Military History
Where you ever in any branch of the U.S. Armed Forces?
Yes
No
If yes, please answer below:
Branch of service
Date of entry into active duty
Date of discharge
Did you serve in the National Guard?
Yes
No
Type of discharge
Rank at discharge
Attach a copy of your separation papers (Form DD-214) or your military ID (DD Form 2) if you are currently active.
Section 9: Criminal History
Conviction Record - You must list all of your convictions, including convictions in Connecticut and in any other state and federal
convictions. Any willful omission (leaving anything out on purpose) will be construed as a false statement (lying) and might
cause your application to be denied.
Dates
Court and location
Charge
Sentence
If you would like to get an official transcript of your criminal history to help you in filling out this section of the application, you can get one
from the Connecticut State Police for a fee of $50 and attach it to this application.
http://www.ct.gov/despp/lib/despp/reports_and_records/
dps-846-c.pdf
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Section 10: Victim Information
Please list the name(s) and approximate age of any victim(s) of your crime(s) and their phone number(s) or address(es) if you know this
information. DO NOT try to get in touch with any victim. If there was no victim to your crime(s) or you do not know the name of your victim
(s), please write “No victim.” or “Victim information unknown.” The Certificate Review Unit will still review your application if you do not know
the information about any victims of your crime(s).
Section 11: Purpose of Application
State your reason(s) for applying for a Certificate of Employability
In your own words, how have you changed since your criminal activity? You may also use this section to tell the Certificate Review Unit
about anything else that you would like it to think about as part of your application. Attach additional sheet(s) if necessary.
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Section 12: Optional Continuation Page
Please use this section to complete any information that you could not fit on the application
Please Number The Section That You Are Continuing
Section number
Response
Section number
Response
Section number
Response
Section number
Response
Section number
Response
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Section 13: Attestation and Background Investigation Authorization
I,
, agree to allow an investigation to be made to determine my fitness for a Certificate
of Employability pursuant to No. 14-27 of the 2014 Public Acts. I hereby state, under penalty of false statement, that I have, to the best of
my ability, fully and truthfully answered all of the questions in this application.
Applicant's signature
Date
I,
, have applied to the State of Connecticut Judicial Branch Court Support Services Division
Certificate Review Unit for a Certificate of Employability. To facilitate the investigation of my application, I hereby authorize any individual,
private business concern, state or federal agency to release any information such person, private business concern, state or federal agency
may have in its possession concerning me or my activities.
Applicant's signature
Date
Subscribed and Sworn before me this
day of
, 20
Signature of Notary Public
Notary seal
My commission expires on
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