Form CT-HR-4 "Personal Service Agreement/Request for Waiver of Classified Service Form" - Connecticut

What Is Form CT-HR-4?

This is a legal form that was released by the Connecticut State Department of Administrative Services - 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 December 1, 2003;
  • The latest edition provided by the Connecticut State Department of Administrative Services;
  • 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 CT-HR-4 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Administrative Services.

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Download Form CT-HR-4 "Personal Service Agreement/Request for Waiver of Classified Service Form" - Connecticut

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State of Connecticut Human Resources
Personal Service Agreement/Request for Waiver of Classified Service Form
Form #: CT-HR-4
Revision Date: 12/2003
_____________________________________________________________________________________________
TO: DAS Human Resources Business Center
450 Columbus Blvd., Hartford, CT 06103
Attn: __________________________
FAX: _______________ PHONE: __________________
(Agency HR Liaison)
FROM: ___________________________________
Name and Title of Personnel Administrator
___________________________________
Agency Name
___________________________________
Agency Address
PHONE: _____________________________
FAX: __________________________
DATE: ______________________________
NAME OF VENDOR: ___________________________ SOCIAL SECURITY NUMBER __________________
CONTRACT PERIOD: Start Date ___________________ End Date ____________________
TYPE OF CONTRACT: _____Original
____ Extension/Amendment*
*If not original, date original contract began _____________________________________________
As requested by the DAS/Human Resources, this office has reviewed the above referenced PSA and
recommends that a waiver of the classified service be :
____Approved ____Denied ____ Approved
Conditionally. The basis for this recommendation is explained below:
EXPLANATION: (Use extra sheets if necessary)
Signature: ____________________________________________________
(
)
Agency Personnel Administrator
This form provided by the Department of Administrative Services
State of Connecticut Human Resources
Personal Service Agreement/Request for Waiver of Classified Service Form
Form #: CT-HR-4
Revision Date: 12/2003
_____________________________________________________________________________________________
TO: DAS Human Resources Business Center
450 Columbus Blvd., Hartford, CT 06103
Attn: __________________________
FAX: _______________ PHONE: __________________
(Agency HR Liaison)
FROM: ___________________________________
Name and Title of Personnel Administrator
___________________________________
Agency Name
___________________________________
Agency Address
PHONE: _____________________________
FAX: __________________________
DATE: ______________________________
NAME OF VENDOR: ___________________________ SOCIAL SECURITY NUMBER __________________
CONTRACT PERIOD: Start Date ___________________ End Date ____________________
TYPE OF CONTRACT: _____Original
____ Extension/Amendment*
*If not original, date original contract began _____________________________________________
As requested by the DAS/Human Resources, this office has reviewed the above referenced PSA and
recommends that a waiver of the classified service be :
____Approved ____Denied ____ Approved
Conditionally. The basis for this recommendation is explained below:
EXPLANATION: (Use extra sheets if necessary)
Signature: ____________________________________________________
(
)
Agency Personnel Administrator
This form provided by the Department of Administrative Services