First Name * Last Name * Employee # * Home Mailing Address * Mobile # Home e-mail Home Phone # Work Phone # Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007 Gender Male Female State Agency * - Select -Auditors of Public AccountsBoard of Ed and Services for the BlindCommunity College - CapitalCommission on Human RightsCommunity College - AsnuntuckCommunity College - HousatonicCommunity College - ManchesterCommunity College - MiddlesexCommunity College - NaugatuckCommunity College - NorthwesternCommunity College - NorwalkCommunity College - QuinebaugCommunity College - Three RiversCommunity College - TunxisCommunity Colleges Board of TrusteesConnecticut Agricultural Experiment StationConnecticut Airport AuthorityConnecticut Development AuthorityConnecticut Housing Finance AuthorityConnecticut Lottery CorporationConnecticut Siting Council OfficeConnecticut State LibraryConnecticut State University - CentralConnecticut State University - EasternConnecticut State University - SoutherConnecticut State University - System OfficeConnecticut State University - WesternDepartment of Administrative ServicesDepartment of AgricultureDepartment of BankingDepartment of Children and FamilyDepartment of Consumer ProtectionDepartment of CorrectionsDepartment of Developmental ServicesDepartment of EducationDepartment of Environmental ProtectionDepartment of Higher EducationDepartment of HousingDepartment of Information TechnologyDepartment of InsuranceDepartment of LaborDepartment of Mental Health and AddictionDepartment of Motor VehiclesDepartment of Public HealthDepartment of Public SafetyDepartment of Public UtilityDepartment of Revenue ServicesDepartment of Social ServicesDepartment of TransportationDepartment of Veterans AffairsEconomic and Community DevelopmentElections Enforcement CommissionEthics CommissionFreedom of Information CommissionMilitary DepartmentOffice of Attorney GeneralOffice of Chief Medical ExaminerOffice of Child AdvocateOffice of Consumer CouncilOffice of Ealy ChildhoodOffice of Governmental AccountabilityOffice of Health StrategyOffice of Healthcare AdvocateOffice of Policy and ManagementOffice of State ComptrollerOffice of State TreasurerOffice of the Claims CommissionerOffice of Victim AdvocateSecretary of the StateState Board of AccountancyTeachers' Retirement BoardUniversity of ConnecticutUniversity of Connecticut - Health CenterWorkers Compensation CommissionDepartment of AgingDESPPOther - Not In This List Agency Location * - Select -AndoverAnsoniaAshfordAvonBarkhamstedBeacon FallsBerlinBethanyBethelBethlehemBloomfieldBoltonBozrahBranfordBridgeportBridgewaterBristolBrookfieldBrooklynBurlingtonCanaanCanterburyCantonChaplinCheshireChesterClintonColchesterColebrookColumbiaCornwallCoventryCromwellDanburyDarienDeep RiverDerbyDurhamEast GranbyEast HaddamEast HamptonEast HartfordEast HavenEast LymeEast WindsorEastfordEastonEllingtonEnfieldEssexFairfieldFarmingtonFranklinGlastonburyGoshenGranbyGreenwichGriswoldGrotonGuilfordHaddamHamdenHamptonHartfordHartlandHarwintonHebronKentKillinglyKillingworthLebanonLedyardLisbonLitchfieldLymeMadisonManchesterMansfieldMarlboroughMeridenMiddleburyMiddlefieldMiddletownMilfordMonroeMontvilleMorrisNaugatuckNew BritainNew CanaanNew FairfieldNew HartfordNew HavenNew LondonNew MilfordNewingtonNewtownNorfolkNorth BranfordNorth CanaanNorth HavenNorth StoningtonNorwalkNorwichOld LymeOld SaybrookOrangeOxfordPlainfieldPlainvillePlymouthPomfretPortlandPrestonProspectPutnamReddingRidgefieldRocky HillRoxburySalemSalisburyScotlandSeymourSharonSheltonShermanSimsburySomersSouth WindsorSouthburySouthingtonSpragueStaffordStamfordSterlingStoningtonStratfordSuffieldThomastonThompsonTollandTorringtonTrumbullUnionUnknownVernonVoluntownWallingfordWarrenWashingtonWaterburyWaterfordWatertownWest HartfordWest HavenWestbrookWestonWestportWethersfieldWillingtonWiltonWinchesterWindhamWindsorWindsor LocksWolcottWoodbridgeWoodburyWoodstockOther Official Job Title * AccountantAccounting Careers TraineeAccounting SpecialistAccounts ExaminerAdjudicatorAdministrative Hearings Attorney 1Administrative Hearings Attorney 2Administrative Hearings SpecialistAdministrative Specialist (Real Estate)Administrative Specialist (Social Compliance)Agriculture Marketing and Inspection Representative 1Agriculture Marketing and Inspection Representative 2Agriculture Marketing And Inspection SupvrAirport Manager 1Airport Operations Assistant SpecialistAirport Operations Coordinator 2Airport Operations SpecialistAll AffectedAssistant AccountantAssistant AdjudicatorAssistant Cash Control OfficerAssistant Director of OperationsAssistant Director of State Fleet OperationAssistant Economic And Community Development AgentAssistant Investment Officer (rc)Assistant Investment Officer Social Compliance (rc)Asst Planning DirectorAssistant Rate Specialist (Public Utilities)Associate AccountantAssociate Accounts ExaminerAssociate EconomistAssociate Financial ExaminerAssociate Fiscal/Administrative OfficerAssociate Fiscal/Administrative Officer (Unclassified)Associate Health Care AnalystAssociate Rate SpecialistAssociate Research AnalystAssociate Research Analyst (rc)Associate Research AttorneyAssociate Retirement and Benefits OfficerAssociate Revenue Processor (Administrative Services)Associate Revenue Processor (Revenue Services)Associate Sales Assessment Ratio Field RepresentativeAssociate Staff Attorney to Employment Security Board of ReviewAssociate Tax Inheritance ExaminerAssociate Utilities Operations AnalystAttorney For The Office Of Protection And AdvocacyBanking Administrative Attorney 1Banking Administrative Attorney 2Banking Asst Div DirectorBanking Associate Examiner (General)Banking Associate Examiner (Securities)Banking Dept MgrBanking Education CoordinatorBanking Principal Examiner (General)Banking Principal Examiner (Securities)Boiler InspectorBookstore Assistant SupervisorBookstore Supervisor 1Bookstore Supervisor 2Braille CoordinatorClaims AnalystClaims SupervisorCollection Services Investigator (RC)Collection Services Investigator Supervisor (RC)Collection Services Manager 1 (RC)Commercial Recording Assistant ManagerCommunications Officer (RC)Communications Specialist (RC)Community Development SpecialistCommunity Development Specialist (rc)Compensation Review Board Chief Law ClerkConnecticut Careers Trainee (Administrative & Residual)Connecticut Marketing Authority Business Services OfficerConsumer Counsel Supervisor Of Utility Financial AnalysisConsumer Information RepresentativeConsumer Protection Assistant Division DirectorConsumer Protection Assistant Division Director (Fraud)Consumer Protection Assistant Division Director (Professional TraConsumer Protection Assistant Division Director (Real Estate)Consumer Protection Automotive Technical ExpertConsumer Protection Inspector (Athletics)Consumer Protection Inspector (Food)Consumer Protection Inspector (Product Safety)Consumer Protection Inspector (Professional Trades)Consumer Protection Inspector (Weights and Measures)Consumer Protection Lead Real Estate ExaminerConsumer Protection Licensing SupervisorConsumer Protection Licensing Supervisor (rc)Consumer Protection Real Estate ExaminerConsumer Protection Supervisor (Central Licensing)Consumer Protection Supervisor (Food)Consumer Protection Supervisor (Product Safety)Consumer Protection Supervisor (Professional Trades)Consumer Protection Supervisor (Real Estate)Consumer Protection Supervisor (Trade Practices)Consumer Protection Supervisor (Weights and Measures)Contract AnalystContract SpecialistContract Team LeaderCorrectional Industries Sales RepresentativeDemhs Fusion Center AnalystDemolition And Crane Operations InspectorDevelopmental Services Program Development Coordinator (rc)Director Of Volunteer ServicesDisability Retirement CoordinatorDOL Unit ManagerDMSSSMEconomic And Community Development AgentEconomic Development Assistant Division Director (rc)EconomistElections Enforcement Commission Staff Attorney 1Elections Enforcement Commission Staff Attorney 2Elections OfficerElevator Inspection SupervisorElevator InspectorEmergency Management Area CoordinatorEmergency Management Program SpecialistEmergency Management Program SupervisorEmergency Management Radiological Equipment Maintenance OfficerEmergency Medical Services Field Program CoordinatorEmergency Medical Services SupervisorEmergency Medical Services Training CoordinatorEnergy & Environmental Protection Supervisor Of EducationEnvironmental Education CoordinatorEnvironmental Protection Education And Firearms Safety CoordinatoEnvironmental Protection Indian Affairs CoordinatorEnvironmental Protection Program Specialist 1Environmental Protection Safety Representative (Boating Safety)Environmental Protection Safety Representative (Firearms Safety)Equities Trading AssistantErp Financials Business AnalystErp Financials Business SpecialistErp Financials Business Team LeadEthics Commission Staff Attorney 1Ethics Commission Staff Attorney 2Financial ExaminerFire Service AnalystFiscal/Administrative AssistantFiscal/Administrative Assistant (Unclassified)Fiscal/Administrative OfficerFiscal/Administrative Officer (Unclassified)Fiscal/Administrative SupervisorFiscal/Administrative Supervisor (Unclassified)Fiscal/Administrative Manager 1Fiscal/Administrative Manager 2Fleet Manager (RC)Fleet Operations Safety CoordinatorFleet Repairs SupervisorForensic Fraud ExaminerFreedom of Information Commission Appellate Attorney (RC)Freedom Of Information Commission Staff Attorney 1Freedom Of Information Commission Staff Attorney 2Grants And Contracts ManagerHandicapped Driver Training ConsultantHealth Care Advocate Prg. ManagerHealth Care AnalystHealth Services Medical Quality Assurance SupervisorHistoric Sites ResearcherHousing Specialist 1Housing Specialist 2Humanities Program CoordinatorInsurance Accredited Financial ExaminerInsurance ActuaryInsurance Associate ExaminerInsurance Associate Examiner (Examination and Market Conduct)Insurance Certified Financial ExaminerfiInsurance Certied Supervising ExaminerInsurance Certified Supervising ExaminerInsurance ExaminerInsurance Examiner (Examination and market conduct)Insurance Financial ExaminerInsurance Holding Co ExamInsurance Principal ExaminerInsurance Principal Examiner (Examination and Market Conduct)Insurance Program ManagerInsurance Supervising Examiner (Examination)Interstate Revenue ExaminerInvestment Accounting AnalystInvestment Officer - Social Compliance (rc)Investment Operations OfficerInvestment Technician 1Investment Technician 2Labor Dept Unit MgrLabor Relations Research AssistantLaw Enforcement Systems AnaystLaw LibrarianLead Boiler InspectorLead Consumer Information RepresentativeLead Economic Development Agent (RC)Lead Legal InvestigatorLead Placement And Training Program AnalystLead Planning AnalystLead Rate SpecialistLead Special Investigator (general)Lead Special Investigator (Medical Examiner)Lead Training CoordinatorLegal InvestigatorLegal Services DeveloperLegislative And Regulations AnalystLegislative And Regulations SpecialistLegislative Services Advisor (RC)LibrarianLibrarian 1 - State LibraryLibrarian 2 - State LibraryLibrary SpecialistLibrary Technical AssistantLibrary TechnicianLicense And Applications AnalystLicense And Applications SpecialistLicense And Applications Supervisor (rc)Licensing Examination AssistantLitigation Attorney, Office of Consumer CounselLottery Financial AnalystLottery Media And Marketing Specialist (RC)Lottery SpecialistLottery SpecialistMaintenance ManagerManagement Analyst 1Management Analyst 2 (rc)Management Analyst 3Medical Records Supervisor 1Medical Records Supervisor 2Mental Health Assistant Director of Program Management ServicesMental Health Services Administrative InternMental Health Services Assistant ManagerMotor Vehicle AnalystMotor Vehicle Branch Manager 1Motor Vehicle Branch Manager 2Motor Vehicle Branch Operations Supervisor 1Motor Vehicle Driver Improvement AnalystMotor Vehicle Driver Improvement Analyst Supervisor (rc)Motor Vehicle Driver Improvement AssistantMV Hub Branch ManagerMotor Vehicle Legal Services AnalystMotor Vehicle Legal Services SpecialistMotor Vehicle Program CoordinatorMuseum Curator 1Museum Curator 2Museum DirectorNational Register Specialist (Archaeologist)National Register Specialist (Architectural Historian)National Register Specialist (Historian)Occupational HygienistOccupational Safety And Health OfficerOccupational Safety OfficerOccupational Safety Training SpecialistOff Track Betting Manager 1Paralegal SpecialistParalegal Specialist 1Paralegal Specialist 1 (Unclassified)Paralegal Specialist 2Paralegal Specialist TraineePayroll Officer 1Payroll Officer 2Payroll System CoordinatorPayroll System SupervisorPenalty Waiver OfficerPension Fund AccountantPension Funds AnalystPlacement And Training Program Analyst 1Placement And Training Program Analyst 2Planning AnalystPlanning AnalystPlanning Analyst SupervisorPlanning SpecialistPreservation Programs SupervisorPrimary Prevention Services CoordinatorPrincipal Adjudicator (RC)Principal Attorney (rc)Principal Cost AnalystPrincipal Financial ExaminerPrincipal Health Care AnalystProgram Assistant - Commission On The ArtsProgram Associate - Commission On The ArtsProgram Specialist-Commission On The ArtsProperty CoordinatorProperty Management LiaisonPublic Records Grant Program SpecialistPublic Utilities Administrative Hearings CoordinatorPublic Utilities Support Services Assistant Supervisor (rc)Public Works Assistant Director Of Facilities OperationsPublic Works Legal Services Staff AttorneyPurchasing and Store ADPurchasing InspectorPurchasing Services Officer 1Purchasing Services Officer 2Purchasing Services Officer 3Quality Assurance CoordinatorQuality Of Life MonitorQuality Of Life Monitor (rc)Rate SpecialistReal Estate ExaminerRecords And Legislative Services Assistant CoordinatorReimbursement AnalystReimbursement Team LeaderReinsurance SpecialistResearch AnalystResearch Analyst (Unclassified)Research Analyst SupervisorResearch AssistantResearch AttorneyRetirement And Benefit System CoordinatorRetirement And Benefits OfficerRevenue Agent 1Revenue Agent 2Revenue Agent 3Revenue Examiner 1Revenue Examiner 2Revenue Examiner 3Revenue Examiner 4Revenue Processor (Administrative Services)Revenue Processor (Revenue Services)Revenue Services Administrative Support Specialist (rc)Revenue Services Internal Control OfficerRevenue Services Tax SupervisorSafety Program OfficerSales Assessment Ratio Field RepresentativeSecretary Of The Connecticut Historical CommissionSecurities AnalystSenior Program Associate - Commission On The ArtsSpecial Investigator (General)Special Investigator (Medical Examiner)Special Investigator (Non-Competitive)Special Revenue Charitable Games Liaison OfficerSpecial Revenue Division JudgeSpecial Revenue Gambling Facilities Liaison OfficerSpecial Revenue Gambling Regulation Facility SupervisorSpecial Revenue InvestigatorSpecial Revenue Lead Gaming Liaison OfficerSpecial Revenue Lead InvestigatorSpecial Revenue Licensing CoordinatorSpecial Revenue Lottery Claims SupervisorSpecial Revenue Lottery SpecialistSpecial Revenue Marketing CoordinatorStaff Attorney 1Staff Attorney 2Staff Attorney 3Staff Attorney To The Employment Security Board of ReviewState ArchivistState Library Unit HeadState Police Message Center SupervisorState Resource Library SpecialistStateInnvtnModelSpecStatisticianSupervising AccountantSupervising Accounts ExaminerSupervising AdjudicatorSupervising Attorney State Ethics CommissionSupervising Special InvestigatorSupervisor Of Education, Safety And Health ServicesSupervisor Of Education, Safety And Health Services (rc)Supervisor Of Food ProcessingSupervisor Of Mail, Duplicating, And Courier ServicesSupervisor Of Record Services For State AgenciesTax Appellate OfficerTax Appellate SpecialistTax Attorney 1Tax Attorney 2Tax Attorney 3Tax Attorney 3Tax Collection Assistant SupervisorTax Collection SupervisorTax Corrections Examiner 1Tax Corrections Examiner 2Tax Corrections Principal ExaminerTax Hearings OfficerTax Operations Assistant Unit SupervisorTax Operations Unit Supervisor354Taxpayer AdvocateTeletrack Line SupervisorTourism Program AssociateTourism Program CoordinatorTourisn Program AssistantTrainerTraining Program CoordinatorTraining Program Coordinator (RC)Training Program SpecialistTransit ManagerTransportation Assist District EngineerTransportation Bridge Safety Prn EngineerTransportation Harbor Liaison OfficerTransportation Material Storage SupervisorTransportation Public Concessions InspectorTransportation Public Concessions SupervisorTransportation Public Transit InspectorUnderwriterUnemployment Compensation Field Examination SupervisorUnknownUtilities Assistant Finance SpecialistUtilities Examiner 1Utilities Examiner 2Utilities Finance SpecialistUtilities Operations AnalystUtilities Principal Finance SpecialistVehicle Control SupervisorVending Facility SupervisorVolunteer Programs ManagerWorkers Compensation Commission District SupervisorWorkers Compensation Education CoordinatorWorkers` Comp Comm District Ops SupvtWorkshop Supervisor 1Workshop Supervisor 2Youth Systems CoordinatorNone Of The Titles Listed Date of State Hire Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Date of Hire Into A&R Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Salary Grade Step Membership Authorization * I elect to join A&R Local 4200 By checking this box, I elect to become a member of A&R Local 4200, AFT-CT, AFT, AFL-CIO. I hereby request and voluntarily accept membership in A&R Local 4200. I authorize A&R Local 4200 to act as my exclusive representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer. Dues Deduction/Checkoff Authorization * I authorize automatic dues deductions By checking this box, I authorize my employer to deduct from my earnings the regular dues payable to A&R Local 4200. This authorization shall be irrevocable unless i revoke it by sending written notice via U.S. Mail to both the employer and A&R Local 4200 during the window period, February 1 -28 of any year. This authorization shall be automatically renewed from year-to-year unless revoked in writing during the window period. Leave this field blank