Free 51729.pdf - Indiana

REQUEST FOR RE-EMPLOYMENT
State Form 51729 (4-04)

Yes Yes

No No

Did you leave merit employment within the previous two (2) years? Did you leave in good standing? Did you have status in the job classification you are interested in applying?

Yes

No

If you answered yes, to all the above questions, you may be eligible for re-employment rights. Complete the following form for each position you are interested in being considered for re-employment and submit with a completed State Employment Application. Name: Social Security Number: (The State is requesting your Social Security number under authority of IC 4-1-8 to accomplish statutory purposes.) Agency Name (where employed before): Job Classification: Dates Employed: I request re-employment consideration into the job classification I am applying for:

(Title of Job Classification).
I certify to the best of my knowledge that the above information is accurate. Signature of Applicant: ________________________________ Date Signed: __________________ Agency Use Only: Agency Verification: Contact the State Personnel Department (Employee Data) to verify the following information: Yes Yes No No Did applicant leave merit employment within the previous two (2) years? Did applicant leave in good standing? Did the applicant have status in the job classification he/she is applying? Does the applicant meet all the requirements for re-employment?

Yes
Yes

No
No

Name(of person verifying information): Title(of person verifying information): Date(date information verified): This completed form must be submitted with the Personnel / Payroll Action Form for all re-employments.