Fillable APPLICATION FOR NEW YORK STATE EXAMINATIONS OPEN TO (New York State)

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APPLICATION FOR NEW YORK STATE EXAMINATIONS OPEN TO (New York State)

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APPLICATION FOR NEW YORK STATE EXAMINATIONS OPEN TO THE PUBLIC
PLEASE CHECK
THE EXAM(S)
YOU ARE
APPLYING
FOR:
20-149 Direct Support Assistant Trainee
20-150 Direct Support Assistant Trainee
(Spanish Language)
NYS-APP #4 20-149 & 20-150 (9/17 L)
SIDE/PAGE 1
Send your completed and signed application to:
Office for People With Developmental Disabilities
facility where you would like to take the examination.
See list of locations available on the examination
announcement at:
Please read the exam announcement carefully
before completing this application.
http://www.cs.ny.gov/examannouncements/announcements/oc-cr/decentralized/20-149.cfm
PLEASE PRINT
Your Last Name
First Name
Social Security Number
Street Number, Apt. or P.O. Box
Home Phone
( ) -
Area Code
City or Post Office
State
Zip Code
Business Phone
( ) -
Area Code
E-mail Address
Cell Phone
( ) -
Area Code
Please note: You may take these Direct Support Assistant Trainee exam(s) only ONCE every test form period.
(See details on the examination announcement.)
EDUCATION
Yes No Do you have a High School or Equivalency Diploma (such as a GED)?
If yes, name and location of High School or Issuing Governmental Authority: _______________________________________________
If your diploma is from an education institution outside of the United States and its territories, please refer to the examination announcement for
information on how to obtain a verification of educational equivalency.
Yes No Do you have a Direct Support Professional (DSP) Certificate from an accredited public or private organization?
If yes, name and location of the Organization: _________________________________________________________________________
You MUST supply a copy of the Certificate with your application.
REASONABLE ACCOMMODATIONS IN TESTING
I require reasonable accommodations to take this test. (See the examination announcement for details.)
FOR ADDITIONAL LANGUAGE PARENTHETIC TITLES: In order to provide the best service to those individuals for whom English is not a
primary language, additional language-specific positions may be created during the life of the list. If you are interested in a language-specific Direct
Support Assistant Trainee position, indicate the language(s) in which you are fluent:
French
Creole
Korean
Russian
Chinese
American
Sign Language
Other
(specify) ___________
ELIGIBILITY FOR EMPLOYMENT: You must be eligible to work in the United States at the time of appointment and throughout your
employment with New York State. If appointed, you must produce documents that establish your identity and eligibility to work in the United States,
as required by the Federal Immigration Reform and Control Act of 1986, and the Immigration and Nationality Act.
MEDICAL EXAMINATION, FINGERPRINTING AND BACKGROUND INVESTIGATION
A medical examination will be required for appointment.
Fingerprinting and criminal background check will be conducted if you are selected for appointment.
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(s) for which they have applied. This information will be used in
accordance with Section 96(1) of the Personal Privacy Protection law, particularly subdivisions (b), (e), and (f). Failure to provide this information may result
in disapproval of the application. This information will be maintained by the Office for People With Developmental Disabilities. For further information,
relating only to the Personal Privacy Protection Law, call (518) 457-9375. For exam information, call (518)457-2487; or toll free at 1-877-697-5627.
It is the policy of the State of New York to provide for and promote equal opportunity employment, compensation, and other terms and conditions of
employment without unlawful discrimination on the basis of age, race, color, religion, disability, national origin, gender, sexual orientation, veteran
or military service member status, marital status, domestic violence victim status, genetic predisposition or carrier status, arrest and/or criminal
conviction record, or any other category protected by law, unless based upon a bona fide occupational qualification or other exception.
It is the policy of the New York State Department of Civil Service to provide qualified persons with disabilities 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 provide such equal opportunity, including accommodations in the examination process. Further, it is the
policy of the Department to provide reasonable accommodations for religious observance.
NOTE: Have you provided all requested information? An incomplete application may be disapproved.
I affirm under penalties of perjury that all statements made on this application (including any attached papers) are true. I understand that all statements made by
me in connection with this 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.
X
Signature of Applicant
Date
Please print any other last name by which you are or have been known
Please continue application on Side/Page 2
click to sign
signature
click to edit
Application for NYS Examinations NYS-APP #4 20-149 & 20-150 (9/17 L)
SIDE/PAGE 2
ADDITIONAL EXAMINATION CREDITS PURSUANT TO CIVIL SERVICE LAW SECTION 85-a
If you are a child or sibling of a firefighter, police officer, emergency medical technician, or paramedic who was killed in the line of duty in the service of New York State, you may be
entitled for additional examination credits pursuant to Civil Service Law Section 85-a. For further information, please contact the Department of Civil Service at (518) 473-6614.
EXTRA CREDITS FOR WAR TIME VETERANS
COMPLETE THIS SECTION ONLY IF YOU: Wish to claim War Time Veteran Credits, AND have not used DISABLED veteran credits for a permanent appointment to a position in
New York State or Local Government.
Answering questions in this section means that you are requesting extra credits as either a non-disabled veteran or a disabled veteran. All veterans are encouraged to answer questions in this section of the
application to ensure that appropriate points are added to passing examination scores. Veterans who answer “YES” to questions 1, 2, AND 3 may receive tentative credits as a non-disabled veteran; candidates
who also answer “YES” to question 4 may receive tentative disabled veteran credits. If you previously used non-disabled veteran credits to obtain a permanent appointment to a position in New York State or
Local Government, and subsequent to appointment, were certified as a disabled veteran, you may be eligible to receive additional disabled veteran credits by answering “YES” to BOTH questions 5a AND 5b
in this section. NOTE: All veterans claiming extra credit will be required to produce eligibility documentation which will be verified at time of interview. Candidates found ineligible for such credit will have
the points subtracted from their examination score(s). If it is determined that veteran credits do not increase one’s reachability for appointment from an eligible list, the use of veteran credits for such
appointment will be waived, and veteran credits can be claimed for future civil service examinations until such time as they are used to receive a permanent appointment as provided by the New York State
Constitution.
1. Yes
No
Do you expect to receive or have you already received a discharge which was honorable or release under honorable circumstances from the Armed Forces of the
United States? The “Armed Forces of the United States” means the Army, Navy, Marine Corps, Air Force and Coast Guard, including all components thereof, 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.
2. Yes
No
Are you now serving, or have you served, on an active duty basis other than active duty for training purposes during one or more of the following Time of War
periods?
In the Armed Forces:
• Aug. 2, 1990 until the Persian
Gulf hostilities end
• Feb. 28, 1961 to May 7, 1975
• June 27, 1950 to Jan. 31, 1955
• Dec. 7, 1941 to Dec. 31, 1946
or earned the Armed Forces, Navy, or Marine
Corps expeditionary medal for service in:
• (Panama) Dec. 20, 1989 to Jan. 31, 1990
• (Lebanon) June 1, 1983 to Dec. 1, 1987
• (Grenada) Oct. 23, 1983 to Nov. 21, 1983
or in the U.S. Public Health Service:
• June 26, 1950 to July 3, 1952
• July 29, 1945 to Sept. 2, 1945
3. Yes
No
Are you a United States citizen or an alien lawfully admitted for permanent residence?
4. Yes
No
Do you have a service connected disability rated at 10% or more by the U.S. Department of Veterans Affairs? This disability must have been incurred during a
Time of War period listed above.
5a. Yes
No
Have you USED NON-DISABLED veteran credits for a permanent appointment to a position in New York State or Local Government?
If you answered "Yes" to "5a" above, you must answer “5b”:
5b. Yes
No
After you were permanently appointed using non-disabled veteran credits, were you subsequently certified as having a service connected disability rated at 10%
or more by the U.S. Department of Veterans Affairs?
New York State Residency Requirement for Extra Credits as a War Time Veteran or Disabled Veteran: You will be required to provide proof of current New York State residency
at time of appointment.
ADDITIONAL QUESTIONS
Certain job titles, including many law enforcement positions (such as Correction Officer, Parole Officer, and Park Patrol Officer) and direct patient care positions (such as Mental Health
Therapy Aide and Secure Care Treatment Aide), are subject to agency criminal history background investigations, as required by law. Applicants should read the official examination
announcement for more specific information.
If you answer YES to either of these questions, you MUST provide an explanation in the REMARKS section provided below:
1.
Yes
No
Were you ever discharged from any employment except for lack of work, funds, disability or medical condition?
2.
Yes
No
Did you ever resign from any employment rather than face a dismissal?
REMARKS:
(Attach additional 8 ½” x 11” sheets if necessary)
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APPLICATION FOR NEW YORK STATE EXAMINATIONS OPEN TO (New York State)

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Completed 22 April 2021

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