Fillable Printable Civil Service Exam Application Form - New York

Civil Service Exam Application Form - New York

1.If you are filing for more than one examination onthis application be sure that theyare all SCHEDULEDTO BE HELDON

THE SAMEDATE(check the announcement for each examination). If you wish to file for examinations being held on

different dates, submit a separate application for each date.

YRS MOS

2. SOCIAL SECURITY NUMBER

ORANGE COUNTY APPLICATION FOR EXAMINATION/EMPLOYMENT

MAIL OR HAND DELIVER TO:

DEPARTMENT OF HUMAN RESOURCES

30 MATTHEWS STREET, SUITE 205

GOSHEN, NY 10924

TELEPHONE: (845) 291-2707

Carefully read the appropriate examination announcementbefore completing this application. This application is part

of your examination and must be filled outcompletely and accurately. Answer all questions fully and carefully. Print

legibly in ink or typewrite.Attach additional sheets if necessary in order to give complete and detailed information.

Exam #s

(if applicable)

Exam Date

(if applicable)

Exam Name/Title of PositionHuman Resources

Use Only

#1 A C D

#2 A C D

#3 A C D

#4 A C D

#5 A C D

3. FULL NAME/LEGAL RESIDENCE*

Last name First Name Initial

Street Address

City State Zip Code

Mailing Address (if different from legal residence)

Phone #

*NOTIFY THIS DEPARTMENT IMMEDIATELY OF ADDRESS CHANGES*

6.VETERANS CREDITS: If you are serving, or have

served, in the armed forces of the United Stateson afull-

time active duty basis during wartime, you maybe eligible

to receive credits as a Disabled or Non-Disabled Veteran.

YES, I WISH TO CLAIM CREDITS AS A NON-DISABLED

VETERAN, PLEASE SEND APPLICATION

YES, I WISH TO CLAIM CREDITS AS A DISABLED

VETERAN, PLEASE SEND APPLICATION

NO, I DO NOT WISH TO CLAIM VETERANS CREDITS

5. SPECIAL ARRANGEMENTS: Checkbox below if you

need special accommodations to participate in the exam:

Religious Observer – for religious reasons cannot

be tested on date of examination.

Other

(requires supporting documentation)

Disabled Persons – under remarks indicate type

of assistance required

4.RESIDENCY: State yourpermanent legal residence and

indicate how long you have resided there continuously, up

to and including the date ofthis application. THIS

SECTION WILL DETERMINE YOUR ELIGIBILITY(IF ANY)

FOR CERTIFICATION ON A RESIDENT LIST.

YRS MOS

VILLAGE OF

TOWN OF

COUNTY OF

STATE OF

SCHOOL

DISTRICT

8. CHECK APPROPRIATE BOX TO RIGHT OF EACH QUESTIONYES NO

A. Were you ever dismissed or discharged from anyemployment for reasons other than lack of work or funds?

B. Did you ever resign from any employment rather than face dismissal?

C. Did you receive a dishonorable discharge from the armed forces of the United States?

D. Have you ever been convicted of any crime (felony or misdemeanor)? If so, please submit a

Certificate of Conviction with your application.

E. Are you now under charges for any crime (felony or misdemeanor)?

F. Have you ever forfeited bail bond posted to guarantee your appearance in court to answer to any

criminal charge?

Convictions will not necessarily disqualify you from taking an exam but may bar you from appointment.

If you answered "YES" toany of the questions above, please provide specifics under "REMARKS". Ifyou elect not to

provide specifics or if such explanation is insufficient, a confidential inquiry will be sent to you.

11.LICENSES:If a license, certificate or other authorization to practice a trade or profession is a requirement of the position

for which you are applying, complete the following question: (attach copy)

Trade/Profession _______________________________City/State _________________________________

License/Certificate # _______________________________Expiration Date _________________________________

Licensing Agency_______________________________IF NOT currently licensed check this box

12.EDUCATION:Do you have a high school or equivalency diploma?YES NO

COLLEGE, UNIVERSITY, PROFESSIONAL OR TECHNICAL SCHOOL INFORMATION

Name & Location of School

Attendance Dates (Mo/Yr)

From To

Course or Major Subject

#Credits

Rec’d

Degree

Rec’d

Date of

Degree

Other Schools or Special Courses

HAVE YOU PREVIOUSLY SUBMITTED PROOF OF EDUCATIONAL ACHIEVEMENTS?YES NO

9.A.If minimum and/or maximum age limits are established for the position please

enter your date of birth:

B.If citizenship is a requirement for the position for which you are applying, please answer the following:

Are you a citizen of the United States?YES NO

C.If not a citizen, do you have the legal right to accept employment in the United States? YES NO

Please provide Alien Registration Number:

D.Are you a retiree from New York State or any civil division thereof? YES NO

E.Are you an Exempt Firefighter? YES NO

Month Day Year

10.Do you possess a license to operate a motor vehicle in New York State? YES NOClass:

14.DESCRIPTION OF EXPERIENCE: Beginning with your most recent experience, describe in detail all employment that is

pertinent to the requiredminimumqualifications indicated on the examannouncement for the title for which you are

applying. Omissions or vaguenesswill NOTbe interpreted in your favor. Ifrelevant volunteer experience is acceptable as

qualifying,describe it in the same way as paid work. Ifyouhave had militaryservicewhich included experience pertinent

to the position, describe such experience as a separate employment. Under "Duties" for each employment describe the

nature of theworkwhich youpersonally performand the percentageoftime spent in each function.Ifyou supervised a

workgroup, state its size and nature and the extent of such supervision. If your title or duties changed materiallyin the

course of your service in any one organization, indicate such change clearly and as a separate employment.

Length of Employment

MO/YR MO/YR

From / to /

Firm NameAddress

# of hours worked per week

(exclude overtime)

Duties (include % of time in eachfunction)

Type of Business

Your Title

Supervisor’s Name & Title

Reason for Leaving

Earnings (Circle One)

$ WK MO YR

Length of Employment

MO/YR MO/YR

From / to /

Firm NameAddress

# of hours worked per week

(exclude overtime)

Duties (include % of time in eachfunction)

Type of Business

Your Title

Supervisor’s Name & Title

Reason for Leaving

Earnings (Circle One)

$ WK MO YR

Length of Employment

MO/YR MO/YR

From / to /

Firm NameAddress

# of hours worked per week

(exclude overtime)

Duties (include % of time in eachfunction)

Type of Business

Your Title

Supervisor’s Name & Title

Reason for Leaving

Earnings (Circle One)

$ WK MO YR

13. Do you object to this department making inquiry regarding your character and qualifications from your present employer?

YES NO If answer is “YES” please explain under REMARKS.

REMARKS:

ALLSTATEMENTS ARESUBJECTTOVERIFICATION. MISREPRESENTATIONS MAY CONSTITUTE CAUSE FOR

DISQUALIFICATION OR DISCHARGE. ITIS ACRIME PURSUANT TO SECTION 210.45 OF THE NEW YORK STATE

PENALLAW, PUNISHABLE AS ACLASS “A” MISDEMEANOR,TO KNOWINGLY MAKEAFALSE STATEMENT

HEREIN.

Background Investigation:Applicants may be required to undergo extensive investigation of criminal historyand

background, which will include a fingerprint check, to determine suitability for appointment. Costsrelated to such investigation

may be borne by the applicant. Failure to meet the standards of investigation may result in disqualification.

For County employment:You maybe required to submit to a pre-employment drug test. Your appointment maybe

conditioned on such test result.

THIS AFFIRMATION AND AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION MUST BE COMPLETED:

By my signature below, I herebyauthorize the Orange County Department of Human Resources, the County of Orange, and/or

its respective Departments, Offices or Agencies to request verbal records or written verification of any or all information

contained herein. I furtherauthorize a review and full disclosure ofallrecordsconcerning me whether saidrecords are ofa

public, private or confidential nature. The intent ofthis authorization is to give myconsent for full and complete disclosure of

records.

I further release the Orange CountyDepartment of Human Resources, the CountyofOrange, and/or its respective

Departments, Officesor Agencies, and their respective officers and/or employeesfromanyand all liability which maybe

incurred asa result ofcollecting suchinformation. Further, mysignature below certifies I have readand fullyunderstand the

“Affirmation and Authorization for Release ofPersonal Information” andhave acknowledged that a photocopyofthis

Application for Examination/Employment containing this release will bevalid as an original thereof, even though said

photocopydoes notcontain an original writingofmysignature. Iaffirm that all statements made onthis application (including

any attached paper) are true under the penalties of perjury.

_____________________________________ _________________ ___________________________________________

SIGNATURE OF APPLICANT DATE PLEASE PRINT ANY OTHER NAME BY WHICH

YOU ARE OR HAVE BEEN KNOWN

CHECK TO MAKE SURE THATALL APPLICABLE QUESTIONS HAVEBEEN ANSWERED. ANINCOMPLETE

APPLICATION MAY RESULT IN DISAPPROVAL. A RESUME MAYNOT BESUBMITTED INLIEU OFCOMPLETING THE

APPLICATION.

The NewYorkState Human Rights Law prohibits discrimination in employment because of age, race, creed, color, national

origin, sexual orientation, militarystatus, sex, disability, genetic predisposition or carrier status, or marital status. Accordingly,

nothing in this application formshould be viewed as expressing, directlyorindirectly, any limitation, specification, or

discrimination as to age, race, creed, color, national origin, sexual orientation, military status, sex, disability, genetic

predisposition or carrier status, ormarital status in connection with employment in the municipalservice of the Countyof

Orange.

ORANGE COUNTY GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER

9/12/2013