Fillable Printable WYOMING COUNTY CIVIL SERVICE APPLICATION

WYOMING COUNTY CIVIL SERVICE APPLICATION

ARE YOU A CITIZEN OF THE UNITED STATES ?

IF NOT, DO YOU HAVE THE LEGAL RIGHT TO ACCEPT EMPLOYMENT IN THE UNITED STATES?

(Non-citizens may be required to produce 1-151 or 1-1551 Alien Registration Card at time of appointment)

____Yes ____ No

EMPLOYMENT PREFERENCES: Please check the type of work you would be willing to accept.

Full-Time

Part-Time

Temporary

PLEASE CHECK THOSE AGENCIES IN WHICH YOU WOULD BE WILLING TO ACCEPT WORK:

County

Towns

Villages

School Districts

COUNTY OF

CITY, TOWN,

OR VILLAGE OF

STATE OF

WYOMING COUNTY CIVIL SERVICE

143 North Main Street, Suite 220, Warsaw NY 14569

Phone: (585) 786-8830

Fax: (585) 786-0811

APPLICATION FOR: EMPLOYMENT ________ OR EXAMINATION # _______________

PRINT OR TYPE

ANSWER ALL QUESTIONS

Name

LAST FIRST MIDDLE

Home

Address

NUMBER STREET CITY STATE ZIP

Mailing

(if different)

Address

NUMBER STREET CITY STATE ZIP

1 5/2011

Position Title Exam Number

HOME PHONE WORK

CELL

SOCIAL SECURITY NUMBER:

DATE OF BIRTH – For Law Enforcement Only: ______________________________

LEGAL

RESIDENCE

NAME YEARS MONTHS

PLEASE CHECK SCHOOL

DISTRICT IN WHICH YOU RESIDE

Attica _____ Letchworth _____

Perry

_____

Pioneer _____

Warsaw

Wyoming

Other ________________

_____ _____

CHANGE OF ADDRESS: You must notify this agency immediately of any change of address. The number and title of the examination or eligible

list must also be included in this notification. FAILURE TO COMPLY MAY RESULT IN YOUR NAME BEING REMOVED FROM AN

ELIGIBLE LIST.

Call this agency immediately if you do not receive a notice within seven days of the date of the examination informing you whether or not you are

to be admitted.

Home Phone # _________________________ Cell Phone #________________________

FOR CIVIL SERVICE USE ONLY

Approved Date

Disapproved

Conditional

Paid

H/S OR GED (Circle one)

Name:

(If GED, Include

Number)

COLLEGE

Name:

GRADUATE SCHOOL OR

OTHER EDUCATION

Name:

NAME OF COURSE CREDIT HRS. NAME OF COURSE CREDIT HRS.

Yes

SPECIAL COURSES TAKEN:

Court or under a youthful offender law.) Convictions will not necessarily disqualify you from employment

IF YES YOU MUST ATTACH A LIST

OF VIOLATIONS WITH DATES OF CONVICTION AND RESULTANT PENALTIES ON A SEPARATE SHEET OF PAPER.

*Yes

Have

you ever been discharged or resigned from employment for reasons other than lack of work or funds? *If YES,

YOU MUST ATTACH AN EXPLANATION FOR EACH DISCHARGE OR RESIGNATION ON A SEPARATE SHEET OF PAPER.

EDUCATION:

LIST NAME

REQUESTED BELOW

MAJOR

AND

MINOR

TYPE OF

DEGREE

OR DIPLOMA

CREDITS

RECEIVED

DATE

DEGREE/

DIPLOMA

OR GED

RECEIVED

EXPECTED

TRANSCRIPT(S) OR DEGREE(S) IF REQUIRED AS PART OF MINIMUM QUALIFICATIONS (CIRCLE ONE)

Copy Attached Copy Requested

LICENSES/CERTIFICATES OR OTHER AUTHORIZATIONS TO PRACTICE A SKILL, TRADE, OR PROFESSION:

SKILL, TRADE, OR

PROFESSION

LICENSE OR

CERTIFICATE

NUMBER

ISSUED BY:

(Name or City,

State, or Agency)

LICENSE DATES

(Mo./Day/Yr.)

PERMANENT

From To

DRIVER’S LICENSE INFORMATION:

NONE

NEW YORK STATE OUT OF STATE (Indicate State)

MOTORISTID #

CLASS

RESTRICTION(S)

ENDORSEMENT(S)

EXPIRATION DATE

*Yes

No Have you been convicted of a violation of law (Felony/Misdemeanor)? (Omit any offense adjudicated in Juvenile

*Yes

No Are you under age 18?

IF YES, YOU WILL BE REQUIRED TO SUPPLY A WORK PERMIT.

HIGHER EDUCATION LOAN INFORMATION:

Section 50-b of NYS Civil Service Law requires that all applicants for examination be asked the following:

NAME

ADDRESS

DATE

SIGNATURE

EXAM NO. & TITLE

Do you have an outstanding NYS Guaranteed Student Loan?

If yes, are you currently in default on any such Loan?

YES

*Yes

No Have you ever worked for Wyoming County before? IF YES, WHEN AND UNDER WHAT NAME.

___________________________________________________________________________________________

WORK EXPERIENCE: DO NOT SUBSTITUTE A RESUME FOR THIS SECTION. Complete all information requested. Describe in detail all duties performed

which are relevant to the position for which you have applied. List most current employment first. A resume may be attached to supplement the part that states your job

duties. ADDITIONAL SHEETS MAY BE ATTACHED. Sheets must contain ALL information requested. (e.g. Number of hours worked per week, etc.)

Full-Time is 30+ hours per/week

Part-Time is rated as follows: 0-09 hours/week=0

10-19 hours/week=1/4

20-29 hours/week=1/2

Length of Employment

Month/Year to Month/Year

Employer: Employer Address: Employer Phone Number:

Hours Worked per/week: Hourly Wage: Job Duties:

Your Title:

Type of Business:

Name and Title of Supervisor:

May we Contact? Yes ____ No ____

Reason for Leaving:

Length of Employment

Month/Year to Month/Year

Employer: Employer Address: Employer Phone Number:

Hours Worked per/week: Hourly Wage: Job Duties:

Your Title:

Type of Business:

Name and Title of Supervisor:

May we Contact? Yes ____ No ____

Reason for Leaving:

Length of Employment

Month/Year to Month/Year

Employer: Employer Address: Employer Phone Number:

Hours Worked per/week: Hourly Wage: Job Duties:

Your Title:

Type of Business:

Name and Title of Supervisor:

May we Contact? Yes ____ No ____

Reason for Leaving:

NON-DISABLED VETERAN _______

VETERANS AND DISABLED VETERANS: If you have served or are currently serving in the Armed Forces of the U.S.A., in a

designated time of war, and wish to claim additional examination credits, you must file a separate “Application For Veteran’s

Credit” VC-1 form to be mailed to you by placing a check mark in this area ( ).

IF YOU WISH TO CLAIM CREDITS, PLEASE CHECK THE APPROPRIATE CHOICE:

DISABLED VETERAN ___________

CURRENTLY IN ARMED FORCES _________

Religious Observance Disability

Alternate Date Needed

(Attach an explanation of your need for special testing accommodations on a separate sheet.)

Cross-filing – Exam Number & Title & Location of Other Exam(s) ____________________________

SPECIAL TESTING ACCOMMODATIONS: Check below if you require special testing accommodations due to:

Please indicate the exam site at which you wish to be tested: ______________________________________________

WYOMING COUNTY AN EQUAL OPPORTUNITY EMPLOYER

It is the policy of the Wyoming County Civil Service Office to provide accommodations in testing to individuals with disabilities and

religious observers and to provide for and promote equal opportunity employment, compensation, and other terms and

conditions of employment to all employees and applicants without regard to race, color, religion, creed, sex/gender, sexual orientation,

predisposing genetic characteristics, national origin, age, physical and/or mental disability, marital status and/or military status, arrest

history or criminal conviction status, status as a domestic violence victim or covered veteran’s status or status as a member of any

other protected group in accordance with applicable federal, state and local laws.

VETERANS CREDITS

All claims and grants of veterans’ credits are tentative and must be verified through inspection of discharge papers and other related

documents, prior to the establishment of the eligible list. You will be advised as to which documents must be produced for this

verification. All statements you make in support of your claim for additional credits are subject to investigation by this agency. In the

event of subsequent disclosure of any material misstatement or fraud in this claim, your appointment may be rescinded. You may also

be disqualified from further appointment on which you have been granted additional credits as a result of material misstatement or

fraud. Persons claiming credits as disabled war veterans may be contacted by this agency for additional information

IMPORTANT: This section MUST BE completed. Failure to sign this section will result in disapproval of your

application for employment or examination.

Affidavit: I certify that the answers provided by me in this application are true and complete to the best of my

knowledge, and I understand that any omission, falsification, or misrepresentation of information by me in this

application is grounds for refusal to hire or, if I have been hired, for termination and I release Wyoming County

from any liability if I am terminated because of any material misstatements, omissions, or false information

provided on this application. I hereby confirm that I have never had my professional license, registration or

certifications revoked, suspended, denied, restricted, limited or placed in a probationary status, nor do I have

any knowledge that my professional license, registration or certification is currently under investigation except

as disclosed in this application.

I authorize the County to investigate my background, references, employment record, criminal conviction

record, and other matters related to my suitability for employment. This specifically includes, without

limitations, a criminal background check. I also authorize my former employers or any third party to disclose to

the county all reports without giving me prior notice of such disclosure. I hereby release the County, former

employers, and all references listed above from any and all claims, demands, or liabilities arising out of, or

related to such investigation or disclosure. A copy of this Authorization shall have the same force and effect as

the original.

I also understand that a conditional offer of employment may be based on the results of a later medical

examination and drug screening to determine whether I meet the physical requirements of the job for which I

am hired. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of Wyoming

County.

Signature:

Date

ALL STATEMENTS ARE SUBJECT TO VERIFICATION