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NOTICE OF DISQUALIFICATION AND APPEAL RIGHTS
This form MUST be returned with your application.
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Please print the requested information in the spaces provided below and return this form with application.
CLASS / JOB TITLE:
NAME (PLEASE PRINT):
SOCIAL SECURITY NUMBER:
DISQUALIFICATION INFORMATION: Candidates may be disqualified for the following reasons:
ü Failing to follow the directions provided in the instructions
ü Failing to return this form with the other required paperwork
QUESTIONS ABOUT THE EXAM CONTENT OR CONDUCT:
If you have questions concerning the content or conduct of this examination, you may contact the office that scheduled your examination to attempt to resolve any questions you may have concerning the examination. You must contact the office within 5 days from the date of the exam.
APPEAL RIGHTS:
You have the right to appeal if you believe the content or conduct of this examination was arbitrary, capricious or contrary to rule or law. Scores and ranks are not considered as conduct or content of an examination. Your appeal should contain, as a minimum, the following information: 1) your name, address, and work and home telephone number, and the name, address and phone number of your representative, if any; 2) name of the agency and address that conducted the examination being appealed; 3) specific action/issue(s) being appealed; 4) reason you believe the content and conduct of the examination was arbitrary, capricious, or contrary to rule or law; 5) specific remedy or relief requested; and 6) the date you participated in the examination or the date you received your due process rights pertaining examination appeals, whichever is later. Your appeal must be submitted in writing on the official appeal form, signed by you or your representative, and must be received at the following address no later than ten (10) calendar days from the date the examination was administered. If you appeal, please address your appeal as follows:
State Personnel Board
633 17th Street, Suite 1320
Denver, CO 80202-3604
OR fax it to 303-866-5038
Note: Appeals of alleged discrimination in connection with selection activity must be filed with the State Personnel Board at the above address or with the Civil Rights Division within 10 days of the alleged discriminatory practice.
CERTIFICATION:
I understand that I will be disqualified from the examination process for any of the reasons stated above. I further certify that I have read and understand my appeal rights.
SIGNATURE: DATE:
