Fillable County of Ulster Application for Examination or Employment (Ulster County Community College)

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County of Ulster Application for Examination or Employment (Ulster County Community College)

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County of Ulster Personnel Department • 244 Fair Street, 5th Floor, PO Box 1800, Kingston, NY 12402 • 845-340-3550 • http://ulstercountyny.gov/personnel • Revised 03/2015
Length of Residency (Yrs./Mos.)
School District
Town
Village
County
State
County of Ulster
Application for Examination or Employment
Leave this space blank.
Date Received:
Title of Exam or Position for which you are applying:
____________________________________________________
Exam # (if applicable): ___________________
Leave this space blank.
Approved: ________
Disapproved: ________
Conditional: ________
INSTRUCTIONS AND INFORMATION
COMPLETING THIS APPLICATION - This application is part of your examination. Answer all questions fully and carefully. Print in ink. Attach additional sheets if necessary in order to give complete and detailed information. All statements are
subject to verification.
ANNOUNCEMENT OF EXAMINATION - Carefully read the examination announcement before filling out your application.
ADMISSION TO EXAMINATION – Contact the Ulster County Personnel Department immediately if you do not receive notice within three days of the examination informing you whether or not you are to be admitted to the examination.
FILING FEE - There is a non-refundable filing fee for the examination for which you are applying. Please refer to the examination announcement. The non-refundable filing fee may be waived as described on the examination
announcement.
MAIL OR DELIVER TO: Ulster County Personnel Department, County Office Building: 244 Fair St., Box 1800, Kingston, NY 12402-1800. Telephone: (845) 340-3550.
Name: _______________________________________________________________________________ Social Security Number: ______-____-______
Last First MI Suffix
Please state any other name(s) previously used in education or employment: _____________________________________________________
Mailing Address:
______________________________________________________________________________________________________________________________
Street or P.O. Box (
if P.O. Box, fill in Residence Address below) City State ZIP
Physical Address:
______________________________________________________________________________________________________________________________
Street (
if P.O. Box or different than Mailing Address) City State ZIP
Primary Phone: ________________________________________ Secondary Phone: _____________________________________________
Email Address: _________________________________________________________________________________________________________________
Are you currently a United States citizen? Yes No If not, please provide alien registration number: _____________________
Are you 18 years of age? Yes
No If you are under 18, you will need to provide current working papers.
If the position for which you are applying has minimum/maximum age limits (per announcement,) please enter your birth date:
_____________________________________________ (MM/DD /YYYY)
Do you possess certification as an exempt volunteer firefighter? Yes
No
If you have ever been employed by the County of Ulster or any civil division therein (city, town, village, school district, or special district,) please state
location(s) and date(s) of employment:
_________________________________________________________________________________________________________________________________
The County of Ulster is an Equal Opportunity Employer
State your current permanent legal residence for
each of the geographic areas below, indicating
the length of continuous residence to date.
APPLICATION FOR EXAMINATION OR EMPLOYMENT Page 2
County of Ulster Personnel Department • 244 Fair Street, 5th Floor, PO Box 1800, Kingston, NY 12402 • 845-340-3550 • http://ulstercountyny.gov/personnel • Revised 03/2015
1. Are you now serving or have you ever served in the
Armed Forces of the United States on a full-time active
duty basis other than active duty for training purposes?
Yes
No
If "No", omit questions 2 through 5.
2. If you served in the Armed Forces of the
United States, did you receive a discharge which
was other than honorable? Yes
No
NOTE: A DISHONORABLE DISCHARGE OR BAD CONDUCT
DOES NOT AUTOMATICALLY DISQUALIFY YOU.
3. Did you serve in the Armed Forces of the United
States during any of the following periods?
A. December 7, 1941 to December 31, 1946
B. June 27, 1950 to January 31, 1955
C. December 22, 1961 to May 7, 1975
D. August 2, 1990 to "date to be determined"
E. U.S. Public Health Service: July 29, 1945 to
December 31, 1946, or June 27, 1950 to July 3, 1952
Yes
No
Did you receive an expeditionary medal for any of the
following conflicts?
F. Lebanon - June 1, 1983 to December 1, 1987
G. Grenada - October 23, 1983 to November 21, 1983
H. Panama - December 20, 1989 to January 31, 1990
Yes
No
I. I am currently on active duty (for other than training
purposes).
Yes
No
4. Since January 1, 1951, have you ever used additional
credits as a veteran for appointment to any position in
the public employment of New York State or any of its
civil divisions?
Yes
No
5. Are you: A non – disabled war veteran ______
A disabled war veteran ______
Disabled and non-disabled war veterans who are
eligible for additional credits must submit an
application for veterans' credits. Candidates who wish
to claim veterans' credits on an examination should
request this application from the Ulster County
Personnel Department. The completed forms must be
received in the office before the eligible list for this
examination is established.
6. Do you have a valid license to operate a motor
vehicle in New York State? ______ Yes - Class ____
______ No
7. FOR EXAMINATION PURPOSES ONLY: Check below if
you desire special status because you are a:
A. _____Sabbath Observer and cannot be tested on
Saturdays for religious reasons.
B. _____ Disabled Person: Indicate type of assistance
required under "REMARKS" on the last page of this
application.
8.
EXAMINATIONS IN OTHER JURISDICTIONS - Candidates
wishing to participate in additional examinations for
New York State or other jurisdictions on the same day,
must apply individually to each jurisdiction. If you intend
to do this indicate, under "REMARKS" on the last page of
this application, the jurisdictions to which you have
applied, and the examination site at which you plan to
compete. New York State examinations must be taken
at state examination sites. Requests for this type of
consideration may not be approved if received after
the announced last file date for the examination.
The following sections on education and work experience must be filled in completely. A resume is not sufficient.
9. Have you graduated from high school? Yes
No If not, what grade did you complete?_____________
Name of school/issuing agency________________________________________________________________________________
Address: ______________________________________________________________________________________________________
Equivalency diploma #: _______________________
For College, University, Professional, Technical and other schools or special courses, please provide copies of transcripts.
Name of school and its location
Dates of
Attendance
From:__/__To:__/__
( month/ year)
Full or
Part
Time
# of years
credited
Did you
Graduate?
Type of
Course
or Major
No. of
College
Credits
Received
Degree
Earned
Date of
Degree
____/____ To ____/____
____/____ To ____/____
____/____ To ____/____
____/____ To ____/____
APPLICATION FOR EXAMINATION OR EMPLOYMENT Page 3
County of Ulster Personnel Department • 244 Fair Street, 5th Floor, PO Box 1800, Kingston, NY 12402 • 845-340-3550 • http://ulstercountyny.gov/personnel • Revised 03/2015
10. DESCRIPTION OF EXPERIENCE: In listing your experience, be more specific in describing those which relate to the position for which
you are applying. Begin with your most recent employment. You are responsible for submitting an accurate, adequate and clear description of
your experience. Omissions or vagueness will not be resolved in your favor. Include military service experience when appropriate. Relevant
volunteer (unpaid) experience will be considered if verified and fully documented (unless otherwise stated on the examination
announcement). If your title or duties changed materially in the course of your service in any one organization, indicate such change clearly
and as a separate employment. (If more space is needed, attach 8" x 11" sheets of paper using the same format.)
Length of Employment (Mo/Yr)
Firm Name Address City and State Earnings (Select One) Type of Business
From____/____ To____/____
$__________ (Wk / Mo / Yr)
Your Exact Title
Name of your Supervisor Supervisor's Title
No. of hours worked per week
(exclusive of overtime)
________
DUTIES: Describe the nature of the work personally performed by you, with estimates of percentages of time spent on each type of work.
State size and kind of working force, if any, supervised by you and the extent of such supervision.
Length of Employment (Mo/Yr)
Firm Name Address City and State Earnings (Select One) Type of Business
From____/____ To____/____
$__________
(Wk / Mo / Yr)
Your Exact Title
Name of your Supervisor Supervisor's Title
No. of hours worked per week
(exclusive of overtime)
________
Length of Employment (Mo/Yr)
Firm Name Address City and State Earnings (Select One) Type of Business
From____/____ To____/____
$__________ (Wk / Mo / Yr)
Your Exact Title
Name of your Supervisor Supervisor's Title
No. of hours worked per week
(exclusive of overtime)
________
Length of Employment (Mo/Yr)
Firm Name Address City and State Earnings (Select One) Type of Business
From____/____ To____/____
$__________ (Wk / Mo / Yr)
Your Exact Title
Name of your Supervisor Supervisor's Title
No. of hours worked per week
(exclusive of overtime)
________
APPLICATION FOR EXAMINATION OR EMPLOYMENT Page 4
County of Ulster Personnel Department • 244 Fair Street, 5th Floor, PO Box 1800, Kingston, NY 12402 • 845-340-3550 • http://ulstercountyny.gov/personnel • Revised 04/2016
11. Licenses: If a license, certificate or other authorization to practice a trade or profession is listed as a requirement on the announcement of the examination(s)
or position(s) for which you are applying, complete the following. If not currently licensed check this box 
Name of trade or profession License Number Granted by (Licensing Agency)
City or State Specialty Date License First Issued Registered (Mo/Yr)
From: _____/_____ To: _____/_____
12. REMARKS:
13. AFFIRMATION AND AUTHORIZATION TO RELEASE
I affirm that the statements made on this application and any attached papers or documents are true under the penalties of
perjury.
I hereby authorize the Ulster County Personnel Department, or any person acting on their behalf, to investigate and receive
information about me related to the verification of my qualifications and eligibility for the examination or the position for
which I am applying. Further, I authorize any person who receives a request to disclose information related to this application,
to release any or all information about me to which such person may have access. I specifically authorize such disclosures
and agree to hold harmless all corporations, agents or persons who request or release such information.
Special Requirement for Appointment to Ulster County Positions:
Following the interview process, a prospective Employee will undergo required Criminal Background Checks and
Fingerprinting after signing a Criminal Background Investigation Release Form. In accordance with Ulster County Legislative
Local Law 14 of 2007 (codified as Article1, Section 98 of the Ulster County Code) or by any other applicable State and
Federal Statutes, candidates for prospective employment to all Ulster County positions must obtain fitness for appointment by
review and consideration by the County based on the New York State Division of Criminal Justice Services or other mandated
State and Federal regulatory authority. Nor shall the County be precluded from withdrawing conditional offers of
employment for any lawful reason, including the determination that the candidate has a conviction that bears a direct
relationship to the duties and responsibilities for the position sought, or their hiring would pose an unreasonable risk to
property or to the safety of individuals or the general public
.
Check here to indicate that you do not wish your present employer to be contacted at this time.
SIGNATURE________________________________________________________ DATE__________________________
The New York State Human Rights Law prohibits discrimination in employment because of age, race, creed, color, national origin, sexual orientation, military status, sex,
marital status, or disability. Accordingly, nothing in this application form should be viewed as expressing, directly or indirectly, any limitation, specification or discrimination
as to age, race, creed, color, national origin, sexual orientation, military status, sex, disability, or marital status in connection with employment in the municipal service of
Ulster County. It is the policy of Ulster County to provide equal opportunity to all employees and applicants for employment without regard to age, race, creed, color,
national origin, sexual orientation, military status, sex, disability, marital status or any other protected status.
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County of Ulster Application for Examination or Employment (Ulster County Community College)

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Completed 21 September 2020

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