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ESSEX COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER
Es s ex County De partm e nt o f Pe rs o nne l and Civil Service
7551 Court S treet, PO Box 217, Elizabe thtown NY 12932
Phone : (518) 873-3360 / Fax: (518) 873-3372
APPLICATION FOR EXAMINATION OR EMPLOYMENT
For County, Towns, Villages and School Districts
Title of Position Applying For Exam No. (if applicable)
This application is part of your examination, ANSWER ALL QUESTIONS FULLY AND CAREFULLY. Print in ink or
type. Attach additional sheets if necessary in order to give complete and detailed information.
ALL STATEMENTS ARE SUBJECT TO VERIFICATION.
PO Box and/or Street Town/City State Zip Code:
Immediate Notice should be given if any changes in address before or after examination.
5. State your actual permanent legal residence and indicate for how long you
have resided there continuously, up to and including date of this application:
Social Security Number:
Date of Birth:
6. Check appropriate box to the right of each question:
A. Were you ever dismissed or discharged from any employment for reasons other than lack
of work or funds?
B. Have you ever been convicted of any crime, (Felony or Misdemeanor)?
C. Are you now under any charges for any crime?
If "yes", give particulars and disposition of each charge on separate sheet and attach same.
NONE OF THE ABOVE CIRCUMSTANCES REPRESENT AN AUTOMATIC BAR TO EMPLOYMENT. EACH CASE IS
CONSIDERED AND EVALUATED ON INDIVIDUAL MERITS IN RELATION TO THE DUTIES AND RESPONSIBILITIES OF
THE POSITION(S) FOR WHICH YOU ARE APPLYING.
7. Check appropriate box to the right of each question:
A. Are you currently a U.S. Citizen?
(Citizenship is no longer a requirement for employment except for public officer positions)
B. If not a U.S. Citizen, do you have a legal right to accept employment in the United States?
Please give alien registration number:
Are you a retiree from New York State or any civil division thereof?
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Village or City of:
Home Phone #:
Last Name First Name Middle Name
Are you an exempt Volunteer Fireman?
Cell Phone #:
E. Do you have a valid license to operate a motor vehicle in New York State?
F. If Yes, please provide the following:
Note: If a driver's license is required for the position applying for, a copy must accompany your application.
Class: Number: Date of Expiration: