Fillable APPLICATION FOR CIVIL SERVICE EXAMINATION (City of Binghamton)

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APPLICATION FOR CIVIL SERVICE EXAMINATION (City of Binghamton)

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APPLICATION FOR CIVIL SERVICE EXAMINATION
MUNICIPAL CIVIL SERVICE COMMISSION OF THE CITY OF BINGHAMTON
38 Hawley Street – City Hall 4
th
Floor, Government Plaza, Binghamton, New York 13901
www.cityofbinghamton.com
FOR CIVIL SERVICE USE ONLY Raw Score________
Veterans ________
Approved___ Disapproved___ Reviewer’s Initials________ Seniority ________
Final Score __________
Comments:____________________________________________________________________________________________
___________________________________________________________
A non-refundable processing fee is required at the time of application. Make check or money order payable to the “City of
Binghamton”. Applications and/or processing fees will not be accepted after the Last Date to File. Services charges apply on
checks returned for insufficient funds.
Check # and Amount_______________________ Money Order___________________________
INSTRUCTIONS TO APPLICANTS
1. Candidates must be legal residents of the City of Binghamton for at least one month immediately preceding the examination
date unless otherwise stated on the Examination Announcement.
2. A false statement knowingly made in this application, or any deception or fraud on your part will be cause for disqualifying
your examination papers or removal from the service upon charges as provided by law.
3. Please answer all questions completely and accurately in regard to your past experience which would qualify you for the
position you are seeking.
4. Defective applications may be suspended by the Commission and applicants notified to amend the same, but the
Commission shall not be compelled to give such notice or grant such opportunity a second time.
________________________________________________________________________
THE CITY OF BINGHAMTON IS AN EQUAL OPPORTUNITY AND AFFIRMATIVE ACTION EMPLOYER
EXACT EXAMINATION TITLE AND NUMBER AS STATED ON ANNOUNCEMENT:
A separate application must be completed for each examination.
Exam Title: __________________________________________________ Exam No.: __________________
NAME AND LEGAL RESIDENCE: (Immediate notice should be given in writing to the Civil Service Office of any
information changes)
1.____________________________________________________________________________________________
Last Name First Name M.I. Social Security Number
2.____________________________________________________________________________________________
Street City State/Zip Code
3. ___________________________________________________________________________________________
Home/Cell E-mail address
Question 4 is applicable to Police and Firefighter applicants only.
4. DATE OF BIRTH: _______________________________________________________
The New York Law Against Discrimination prohibits discrimination because of age.
5. CITIZENSHIP: Do you have the legal right to accept employment in the United States? (upon employment, appropriate
identification of employment eligibility will be required) Yes
□ No □
6. How long have you resided continuously in the City of Binghamton immediately preceding this application?
Years
Months
7. VETERAN CREDITS: Do not fill out this section unless you wish to claim War Time Veterans Credits and Have
Not used veterans credits for appointment to a position in New York State or Local Government.
Are you a Veteran? Yes □ No □
Did you receive a discharge which was honorable or were you released under honorable circumstances? Yes □ No □
Please complete the attached application for veterans credits and submit your discharge papers.
Please specify claim: Disabled Veteran
□ Non-Disabled Veteran □
Not claiming Veteran Credits
□ Credits previously used □
8. Section 50-b of New York State Civil Service Law requires that any applicant be asked the following regarding those who
have loans made or guaranteed by the New York State Higher Education Services Corporation which are currently outstanding
or that are presently in default of such loan.
Do you have any outstanding NYS Guaranteed Loans? Yes □ No □
Are any of those loans in default? Yes □ No □
9. SPECIAL TESTING ARRANGEMENTS AND REASONABLE ACCOMMODATIONS: Most written tests are held
on Saturdays. If you cannot take the test on the announced test date due to a conflict with a religious observance or practice,
indicate this on your application. We will make arrangements for you to take the test on a different date. We provide
reasonable accommodations for persons with disabilities to take a test. On or before the last date for filing applications, contact
the Civil Service Office at (607) 772-7008 and describe the accommodation you need. Do you need special arrangements or a
reasonable accommodation? Yes
□ No □
10. CONVICTION: Have you ever been convicted of any crime (felony or misdemeanor)? Yes
□ No □
If yes, please give particulars and disposition of each charge on a separate sheet and attach it.
11. Were you ever dismissed from any government or private employment for reasons other than reduction in staff?
Yes
□ No □ If yes, provide details below.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
12. EDUCATION:
Do you have a High School or Equivalency Diploma? Yes
□ No □
If yes, Name and Location of High School or Issuing Governmental Authority: ________________________________
_________________________________________________________________________________________________
Education above high school level:
Name of school Location Course of Major Credits completed Degree Received
Type/Year
__________________ _____________ __________________ __________________ _________________
__________________ _____________ __________________ __________________ _________________
13. LICENSES: Complete the following questions if a license, certificate or other authorization to practice a trade or
profession is listed as a requirement on the examination announcement. If not currently licensed, check here. ___
Name of Trade or Profession______________________ Granted by (licensing agency) _________________________
City or State_________________ Specialty____________________ License Number_________________________
Licensed from______________________ to__________________________
14. If required on the announcement, do you have a valid license to operate a motor vehicle in New York State? Yes___
License number: ___________________ Class: _________________
15. DESCRIPTION OF EXPERIENCE: Beginning with your most recent, list all employment, military service or
volunteer experience that shows you meet the minimum qualifications for the examination(s). You are responsible for an
accurate and clear description of your experience. Applicants may be required to furnish documentation of experience
claimed. If your duties changed materially in the course of your employment in any one organization, indicate the dates of the
changes and describe each job as separate employment. If you supervised, state how many people and the nature of such
supervision. If additional space is needed, attach 8.5” by 11” sheets of paper. Do not send your resume only.
Name and address of employer________________________________________________________________________
Starting Date______________________ Ending Date__________________________
Month/Date/Year Month/ Date/Year
Your Exact Title___________________________________________________________________________________
Supervisors Name & Title__________________________________________________________Phone_____________
Hours worked per week__________________________________
Reason for leaving__________________________________________________________________________________
Description of
duties____________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Name and address employer__________________________________________________________________________
Starting Date______________________ Ending Date__________________________
Month/Date/Year Month/ Date/Year
Your Exact Title___________________________________________________________________________________
Supervisors Name & Title__________________________________________________________Phone_____________
Hours worked per week__________________________________
Reason for leaving__________________________________________________________________________________
Description of
duties____________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Name and address of employer________________________________________________________________________
Starting Date______________________ Ending Date__________________________
Month/Date/Year Month/ Date/Year
Your Exact Title___________________________________________________________________________________
Supervisors Name & Title__________________________________________________________Phone_____________
Hours worked per week________________________
Reason for leaving__________________________________________________________________________________
Description of
duties____________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
BE SURE TO READ THE REQUIRED QUALIFICATIONS ON THE EXAMINATION ANNOUNCEMENT
ALL STATEMENTS ARE SUBJECT TO VERIFICATION
Addendum Attached? Yes
□ No □
16. REFERENCES: Do you have any objection to our contacting present or past employers to verify the above?
Yes
□ No □
If Yes, comment_________________________________________________________________________________
DECLARATION: I declare, subject to the penalties of perjury, that the statements made in this application, including
statements made in any accompanying papers, have been examined by me and to the best of my knowledge and belief are true
and correct. I understand that all statements made in connection with this civil service examination application are subject to
investigation and verification and that a material misstatement or fraud may disqualify me from appointment and/or lead to
revocation of my appointment.
________________________________________ ________________________________________
Signature Date
NOTE: Have you answered all appropriate questions? An incomplete application may be disapproved. An application
will be disqualified if the processing fee or qualifying information is not submitted to the Civil Service Office on or
before the last date to file listed on the examination announcement. This office does not make formal acknowledgement
of the receipt of an application or take responsibility for non-delivery or postal delay.
CROSS FILER INFORMATION
If you plan on taking more than one examination on the same day, please fill out this form completely. If taking a State Exam,
you must sit at the State testing site and the City of Binghamton will send them all the materials needed.
Exam Date: _____________________________________________
Candidate’s Name: ______________________________________
Candidate’s Social Security Number: ___________________
Location Where Candidate Wishes To Take Exam: __________________________
EXAM NUMBER EXAM TITLE LOCATION OF EXAM
_______________ _____________________ __________________
_______________ _____________________ __________________
_______________ _____________________ __________________
VETERAN’S CREDIT INFORMATION
As a Veteran you are eligible to receive additional credit, 5 points, for an open competitive examination or 2.5
points for a promotional examination. Disabled Veterans are eligible to receive 10 points for an open competitive
examination or 5 points for a promotional examination.
In order to receive the additional credits, the below form must be completed and documentary proof must be
provided. Disabled Veteran’s must also provide documentation of disabled status. Please Note: Veteran’s credits
may be added only to a passing exam grade and proof of eligibility must be provided any time between the date of
the application and the establishment of an eligible list.
PLEASE NOTE: If you have used credits on a previous exam, you are not eligible to use them again.
If you have any questions, please contact our office at 607-772-7008. Additional information is located online
through the NYS Civil Service Commission.
Last Name First Name M.I.
Exam Number & Title:
Choose one: Veteran
□ Disabled Veteran □
If Disabled, have you sent authorization for Disability Record to the V.A? Yes □ No □
Service Serial Number:
Dates of Active Service:
I declare, subject to the penalties of perjury, that the statements made on this form and any attachments are to the best
of my knowledge, true, and correct.
Signature: Date:
Application Fee Waiver Request and Certification Form
Civil Service Law Section 50.5(b): “…fees shall be waived for candidates who certify to the state civil service department, a
municipal commission or regional commission that they are unemployed and primarily responsible for the support of a
household, or are receiving public assistance.”
Please fill out the below form if you wish to have the application fee waived and bring documentary proof to
support Civil Service Law Section 50.5(b).
EXAM NUMBER EXAM TITLE DATE OF EXAM
_______________ _____________________ __________________
_______________ _____________________ __________________
_______________ _____________________ __________________
Check the box(es) below that apply to you:
□ I am currently unemployed and I am primarily responsible for support of a household
Please Note: Individuals who can be claimed as a dependent on any other person’s tax return are not eligible to receive
the application fee waiver.
□ Currently receiving Supplemental Security Income (SSI) payments
□ Currently receiving Medicaid benefits
□ Currently receiving Public Assistance (Temporary Assistance for Needy Families/Family Assistance or
Safety Net Assistance) Please provide your Public Assistance Case Number:
□ Certified Job Training Partnership Act/Workforce Investment Act eligible through a State or local social
service agency
Affirmation: I have read the above portion of Section 50.5(b) relating to the waiver of application fees and certify that I am
qualified to receive such waiver for the reasons indicated above. I understand that my claim may be investigated and I may be
disqualified from the listed civil service examination(s) if I make any false statement regarding my eligibility.
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APPLICATION FOR CIVIL SERVICE EXAMINATION (City of Binghamton)

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Completed 2 August 2020

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