Fillable Printable Civil Service Exam Application Form - Oneida
Fillable Printable Civil Service Exam Application Form - Oneida
Civil Service Exam Application Form - Oneida
APPLICATION FOR CIVIL SERVICE EXAMINATION OR EMPLOYMENT
Check appropriate box to the right of each question:
A.
Were you ever dismissed or discharged from any employment for reasons other than lack of work, funds, disability or medical condition?
✲
YES
✲
NO
B.
Did you ever resign from any employment rather than face dismissal? ✲ YES ✲ NO
C.
Did you ever receive a discharge from the Armed Forces of the United States which was other than “Honorable” or
which was issued under other than honorable circumstances?
✲
YES
✲
NO
D.
Are you now under charges for any crime? ✲
YES
✲
NO
E.
Have you ever been convicted of any crime (felony or misdemeanor)? If Yes, attach completed form, Request For Criminal Offense ✲ YES ✲ NO
If you answered “YES” to any of the Questions A-D above, you may give specifics under “Remarks” on page 3 of this application. If you elect not to provide specifics, or
if such explanation is insufficient, you may be required to submit further information. None of the above circumstances represents an automatic bar to employment.
Each case is considered and evaluated on individual merits in relation to the duties and responsibilities of the position (s) for which you are applying.
F. Are you currently or have you ever served in the Armed Forces of the United States? If yes, complete questions for Veterans’ Credits.
✲
YES
✲
NO
VETERANS’ CREDITS(See Instruction F, on page 4) If you wish to claim additional credits complete questions 1-4
✲
Disabled War Veteran (10 Points)
✲
Non-disabled War Veteran (5 Points)
1. Did you receive a discharge which was honorable or were you released under honorable circumstances?
✲
YES
✲
NO
2. Did you serve in the Armed Forces of the United States during any of the following periods? ✲ YES ✲ NO
(12/7/41 – 12/31/46) (6/27/50 – 1/31/55) (02/28/61 – 5/7/75) (Persian Gulf: 8/2/90--present)
(Lebanon: 6/1/83 – 12/1/87) (Grenada: 10/23/83 – 11/21/83) (Panama: 12/20/89 – 1/31/90)
NOTE: Credits for Lebanon, Grenada, and Panama will be limited to those who received the following Expeditionary Medals:
Armed Forces, Navy, or Marine Corps (U.S. Public Health Service: (7/29/45 – 12/31/46) OR (6/27/50 – 7/3/52)
3. Since January 1, 1951, have you received a permanent appointment in New York State using your veterans credits?
✲
YES
✲
NO
4. At the time of this application are you currently a New York State Resident?
✲
YES
✲
NO
THIS AFFIRMATIONMUST BE COMPLETED
I affirm that the statements made on this application (including any attached papers) are
true under the penalties of perjury. (SEE page 4)
(Signature in blue ink)
Date
Indicate any other surname (last name) by which you are or have been known
Application also available on line at www.ocgov.net
Department of Personnel, 800 Park Avenue Utica, NY 13501
John P. Talerico – Commissioner of Personnel
Phone: (315) 798-5726 Fax: (315) 798-6490 Web site: www.ocgov.net
POSITION TITLE EXAM NUMBER
______________________ ________________
SOCIAL SECURITY #: ________________________
Print Last Name First
MI
(
Area Code) Home Phone (Area Code) Business Phone
( ) ( )
Permanent Legal Address (Mailing Address if different)
Street Apt Street Apt
City / Town State Zip Code City / Town State
Zip Code
SPECIAL ARRANGEMENTS
(Optional–See Instruction E, on page 4)
✲
Religious Accommodation ✲
Military✲
Disability
A. Are you a citizen of the United States? ✲YES✲ NO
(If NO, see Instruction H on page 4)
B. Are you or were you an exempt
volunteer firefighter? ✲ YES ✲ NO
If age is required on
announcement for
appointment or to take the
examination, complete
Date OfBirth:
DOB:
____/____/____
Referring to your PERMANENT LEGAL ADDRESS, complete all items which applyto where you live.
NAME Years Months
What School District do you live in and for how long?
What City do you live in and for how long?
What Village do you live in and for how long?
What Town do you live in and for how long?
What Countydo you live in and for how long?
(DATE STAMP BELOW)
✲
Approved
✲
Conditioned
✲
Disapproved
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BE SURE TO ANSWER THIS SECTION.
Section 50-b of the NYS Civil Lawrequires that all applicants for
examination answer the following questions:
1. Have you any loans made or guaranteed by the New York State Higher Education Services Corporation which are
currently outstanding?
✲
YES
✲
NO
2. If yes, are you presently in default on any such loan?
✲
YES
✲
NO
EDUCATION:
Read examination announcement for educational requirements. If specialized coursework is
required, attach transcripts showing the required courses and credit hours you completed.
Have you graduated from high school? IF YES, NAME AND LOCATION OF HIGH SCHOOL YEAR GRADUATED
YES
NO
Do you have a high school equivalency diploma? IF YES, ISSUING GOVERNMENTAL AUTHORITY:
NUMBER DATE OF ISSUE
YES
NO
Name of School OR College and Address Dates of Attendance Type of Course Number ofType of Date
(Month and Year) or College Degree Degree
From To Major Subject Credits Rec’d Rec’d Rec’d
College
University,
Professional
Or Technical
School
Other
Schools
Or Special
Courses
LICENSES:
If a license, or other authorization to practice trade or profession is listed as a requirement on the examination
announcement for which you are applying, complete the following and submit a copy of license with this
application: If not currently licensed check this box.
Name of Trade or Profession License Number Granted by(licensing agency) Cityor State of
Specialty Date of License First Issued Registered From:(Mo./Yr.) To: (Mo./Yr.)
If required on the announcement: Do you have a valid license to operate a motor vehicle in New York State?
YES
NO
DESCRIPTION OF EXPERIENCE
:Beginning with your most recent employer, list all employment, military service,
or volunteer experience that shows you meet the minimum qualifications for the examination. We cannot interpret
omissions or vagueness in your favor. You are responsible for an accurate and clear description of your experience.
(Do not send your resume.) Describe the work which you personally performed. If you supervised, state how many people
and the nature of such supervision.
Dates Employed
MO YR MO YR
/ to /
EmployerAddressCity and State
Hours per week
Job Title
Supervisor's Name
Supervisor's Title
Type of Business
Describe specific work performed and job responsibilities:
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Dates Employed
MO YR MO YR
/ to /
EmployerAddressCity and State
Hours per week
Job Title
Supervisor's Name
Supervisor's Title
Type of Business
Describe specific work performed and job responsibilities:
Dates Employed
MO YR MO YR
/ to /
EmployerAddressCity and State
Hours per week
Job Title
Supervisor's Name
Supervisor's Title
Type of Business
Describe specific work performed and job responsibilities:
Dates Employed
MO YR MO YR
/ to /
EmployerAddressCity and State
Hours per week
Job Title
Supervisor's Name
Supervisor's Title
Type of Business
Describe specific work performed and job responsibilities:
Dates Employed
MO YR MO YR
/ to /
Employer
Address
City and State
Hours per week
Job Title
Supervisor's Name
Supervisor's Title
Type of Business
Describe specific work performed and job responsibilities:
REMARKS: (Use this space to provide any additional information, as necessary. If more space is required, attach additional
81/2 x 11 sheets
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INSTRUCTIONS AND INFORMATION
For more information and help completing the application, call (315) 798-5726
A.EXAM APPLICATION: Before filling out your application, read the examination announcement and/or job description carefully. (available at www.ocgov.net)
This application is part of yourexamination. Answer all questions fully and carefully and make sure all boxes are filled in or checked. Resumes will NOT
be accepted in lieu of application. Print in ink or use typewriter. Attach additional sheets, if necessary, to give complete and detailed information.
•
Applicants must answer every question on the application and make sure it is complete in all respects.
•
Incomplete applications will be disapproved. ALL STATEMENTS ARE SUBJECT TO VERIFICATION.
•
Any subsequent findings of false, misleading or unverified information mayresult in exam disqualification.
•
DO NOT fax application. Faxed applications are not accepted.
B. NON-REFUNDABLE EXAM FILING FEE: Refer to the front of the examination announcement for the required filing fee. Enclose a MONEY ORDER ONLY
for the total amount, made payable to ONEIDA COUNTY. Do NOT send cash or check. IF YOUR APPLICATION IS DISAPPROVED, THE FEE WILL NOT BE
REFUNDED.
APPLICATION FEE WAIVER:You will be allowed a waiver of application fee if you meet the qualifications as stated on the examination announcement
under GENERAL INSTRUCTIONS, Number 14. APPLICATION FEE WAIVER.
C. ADMISSION TO EXAM: Applications are reviewed for qualifying status. If your application is disapproved, you will be notified of the reason. All
amendments to applications are due no later than three days before the scheduled examination. IF YOU DO NOT RECEIVE AN ADMISSION LETTER THREE
(3) DAYS BEFORE THE EXAM DATE, CALL: (315) 798-5726. Collect calls will not be accepted.
D. CHANGE OF ADDRESS: Notify the Oneida CountyCivil Service Department immediately of any change of address.Upon receiving your notification, the
Civil Service Department will send you a change of address form. It is your responsibility to complete and return this form to the Civil Service Department.
Oneida County Civil Service is not responsible for undeliverable mail.
E. SPECIAL ARRANGEMENTS:If you need special arrangements because you are a person with a disability, are requesting a military make-up exam, or
need a religious accommodation you must, EITHER: (1) Check the appropriate box on the first page of the application and indicate the special arrangements
you require in the “REMARKS” section on Page 3; OR (2) Write to our office no later than the last filing date for this exam. Your request must include the exam
number and title, and type of special arrangements required.
Military Services Members: If you apply for an examination during the filing period but are on active duty on the date the examination is scheduled, you may
request a military make-up examination. Contact Oneida County Civil Service at (315) 798-5726 for more information. If you are on active duty or discharged
after the filing period has begun, you may apply for the examination up to ten (10) business days before the test date.
It is the policyof the New York State Department of Civil Service and Oneida County Civil Service to provide qualified persons with disabilities, an equal
opportunity to participate in and receive the benefits, services, programs and activities of the Department, and to provide such persons reasonable
accommodations and reasonable modifications as are necessary, to enjoy such equal opportunity, including accommodations in the examination process.
Further, it is the policy of the Department to provide reasonable accommodation for religious observers.
F. VETERANS CREDITS:Disabled or non-disabled veterans who have served on active duty during the creditable periods of war, who have been honorably
discharged/released, and who are New York State residents at the time of application for examination, will be eligible for veterans’ credits. Eligible veterans
must submit, with their application, a copyof the Honorable Discharge Form (DD-214). The copy ofyour DD-214 must be submitted prior to the
establishment of the eligible list. An option of waiving this credit will be allowed after completion of the examination. An applicant who claims additional credit as
a disabled veteran will be sent the necessaryforms. If you do not receive these forms by an exam date, you should request them from the Oneida County Civil
Service Department.
Candidates currently serving in the Armed Forces of the United States mayapply for veterans’ credit provided the criteria for a veteran is met and proof of
service was in time of war and the discharge or release was under honorable circumstances. Candidates currently serving in the Armed Forces will receive
conditional veterans’ credit until a copy of the Honorable Discharge Form (DD-214) is submitted to the Oneida County Civil Service Department.
(The “Armed Forces of the United States” includes all components of the Army, Navy, Marine Corps, Air Force and Coast Guard, and the National
Guard when in the service of the United States pursuant to call,
as provided by Law, on a full-time, active duty basis, other than active duty for training purposes.)
G. PERSONAL PRIVACY PROTECTION LAW NOTIFICATION: The information which you are providing on this application is being requested pursuant to
Section 50.3 of the New York State Civil Service Law for the principal purpose of determining the eligibility of applicants to participate in the examination for
which they have applied. This information will be used in accordance with Section 96(1) of the Personal Privacy Protection Law, particularlysubdivisions (b), (e),
and (f). Failure to provide this information may result in disapproval of the application. For further information, relating only to the Personal Privacy Protection
Law, call (518) 457-9375.
H. NON-CITIZEN: Ifyou are not a citizen of the United States but have the legal right to work, you must submit with your application a copy of the
document(s) allowing you to work in the United States.
I.BACKGROUND INVESTIGATION: Applicants may be required to undergo a State and National criminal history background investigation, which will include
a fingerprint check, to determine suitabilityfor appointment. Failure to meet the standards for the background investigation may result in disqualification.
Oneida County is an Equal Opportunity/Affirmative Action Employer
It is the policy of the New York State Department of Civil Service and Oneida County to provide for and promote equal employment opportunity
in employment, compensation and other terms and conditions of employment without discrimination because of age, race, creed, color, national
origin, gender, sexual orientation, disability, military status, genetic predisposition, carrier status, political affiliation or belief.
Rev. (07/09)
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