APPLICATIONS WILL BE HELD ON FILE FOR ONE YEAR FROM FILING DATE. Revised 10/16
PERSONAL DATA
12. Do you have the legal right to accept employment in the United States? Yes No
(Non-citizens will be required to produce 1-151 or 1-551 alien registration cards at time of appointment).
13. Have you ever been convicted of a misdemeanor or felony? Yes No
If yes, please give particulars and disposition of each charge on a separate sheet and attach same.
14. If a motor vehicle license is required for the position, please indicate the license you presently possess:
Class A B C D E (circle one) Designate type of commercial license: ___________________
Date of Expiration: ______________/ __________/_______
month day year
15. If a license, certicate or other authorization to practice a trade or profession is a requirement for the position for which you
are applying, please indicate the following:
Name of Trade or Profession _____________________________________________________________________________
License Number ___________________________________ Date From _____________________ To ___________________
Licensing Agency __________________________________________ City/State __________________________________
16. For reference purposes do you have any objections to our contacting present or past employers? Yes No
If yes, comment: ______________________________________________________________________________________
17. Did you qualify as an Exempt Volunteer Fireman as set forth by the criteria in section 200 of the General Municipal Law?
Yes No
18. Did you serve in the armed forces of the United States? Yes No
Branch ____________________________________ Dates ___________________________________________
19. Did you receive a discharge which was honorable or were you released under honorable circumstances? Yes No
20. What made you aware of this vacancy or Broome County employment opportunities?
Personal Reference TV Radio Newspaper
Bulletin Board In the Personnel Ofce Other _______________________________
DECLARATION I agree, if employed, to abide by all the rules and regulations relative to my position. I agree to undergo a
physical examination and authorize the examining physician to render to the Department of Personnel the results of the examination.
I declare 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 any omission, misrepresentation and/
or falsication of information contained in this application may constitute grounds for my dismissal. I give the employer the right to
investigate all references and to secure additional job related information about me. I hereby release from liability the employer and
its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.
21. Signature __________________________________________ Date ____________________________
22. Please print any other surnames (last names) by which you are or have been known.
________________________________________________________________________________
The Immigration Reform and Control Act of 1986, requires that all individuals must provide acceptable documentation that proves
identity and employment eligibility. A listing of acceptable documents can be obtained from the Department of Personnel. Failure to
provide this documentation will affect your chances for employment with Broome County.
