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FULTON COUNTY PERSONNEL DEPARTMENT (County of Fulton)

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  • 179 other fields

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U.S.A. forms for County of Fulton

BROWSE COUNTY OF FULTON (NY) FORMS

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(1) APP/EX.EM 12/19
FULTON COUNTY PERSONNEL DEPARTMENT
1 EAST MONTGOMERY STREET JOHNSTOWN, NEW YORK 12095-2534
PHONE: (518) 736-5574 FAX: (518) 736-1027
ANY AND ALL STATEMENTS MADE ON THIS APPLICATION OR MADE IN CONNECTION WITH IT, INCLUDING ANY
ATTACHMENTS OR AMENDMENTS, ARE SUBJECT TO VERIFICATION.
READ INSTRUCTIONS AND INFORMATION ON BACK BEFORE BEGINNING
RETURN COMPLETED APPLICATION TO THE ABOVE ADDRESS
APPLICATION FOR EXAMINATION OR EMPLOYMENT
________________________________ _______________________________
________________________________ _______________________________
POSITION TITLE EXAMINATION NUMBER
This application may be part of your examination. Answer all questions fully and
carefully. Attach additional sheets if necessary in order to give complete and
detailed information.
1. NAME, MAILING ADDRESS AND PHONE (Please Print)
Last First M.I.
Street Address (Actual residence)
Mailing Address (If different from street address)
City State Zip Code
( ) ( )
Home Phone Business Phone
May we contact you at your Business Phone?  NO YES Hrs: _____________
2. SOCIAL SECURITY NUMBER:
3. Are you 18 years of age or older?  YES NO
If there are minimum/maximum age limits for position give your date of
birth:
4. SPECIAL ARRANGEMENTS FOR EXAMINATION (Refer to Pg. 4 D)
 RELIGIOUS OBSERVER  DISABLED PERSON
 ACTIVE MILITARY SERVICE
4.a. Have you applied for any other Civil Service examinations for
employment with Fulton County, NYS, or any other local government
jurisdiction scheduled on the same date?  YES  NO If yes, you
must make arrangements to take all the examinations at one test site. You
must request and complete form: “Same Day - Multiple Examinations”
and return it to the Personnel Office at the above address.
5. If you are not a citizen of the United States, do you have the legal right to
accept employment in the United States?  YES  NO
(Non-citizens may be required to produce I-151 or I-551 Alien
Registration Cards at time of appointment.)
6. State the name of each location in which you reside and how long you
have continuously resided, up to and including the date of this
application.
I currently live in the following: YEARS MONTHS
State
County
City or Town
(circle one)
School District
7. Exempt Volunteer Firefighter:  NO  YES I am a bona fide member of
the _____________ Volunteer Fire Department and have served in said
department for five years and is so certified to be an exempt volunteer
firefighter in accordance with Section 200 of the General Municipal Law.
8. Check appropriate box to the right of each question:
A. Were you ever dismissed or discharged from YES NO
any employment for reasons other than lack of  
work or funds?
B. Did you ever resign from any employment rather YES NO
than face dismissal?  
C. Did you ever receive a dishonorable discharge from YES NO
the Armed Forces of the United States?  
D. Have you ever pled guilty to or been convicted YES NO
of any crime (felony or misdemeanor)?  
E. Are you now under charges for any crime? YES NO
 
If you answered “YES” to any of the Questions 8 A-C above, give specifics under
“Remarks” on back of this application. If you answered “YES” to Questions D or E
you must complete “Addendum to Exam and Employment Application: Questions
8.D. & 8.E.” None of the above circumstances represents 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.
9. THIS AFFIRMATION MUST BE COMPLETED:
I affirm that all statements made on this application (including any attached
papers) are true under the penalties of perjury. I understand that all statements
made by me in connection with this application are subject to investigation
and verification and that a material mis-statement or fraud may disqualify me
from appointment and/or lead to revocation of my appointment.
SIGNATURE OF APPLICANT DATE
Is additional information relative to a change of name, use of an assumed name or
nickname necessary to enable a check on your work record? (If yes, explain)
FOR FULTON COUNTY PERSONNEL DEPARTMENT USE ONLY
Date Rec’d ______________________________ By_______________________
__________ Receipt Number ___ C ___ M.O. ___ Fee Waived
Veteran Disabled Veteran Veterans Credits Forms Given ____________
(Date)
___ Approved Title: _______________________ Approved By: __________
Title: ______________________ Approved By: __________
___ Disapproved Title: _______________________ Disapproved By: ________
Remarks:___________________________________________________________
___ Appeal Approved ___ Appeal Denied Approved/Denied By: _________
___ Performance Test Waived
Vets Credits: Pending Approved Disapproved Conditional +______
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(2) APP/EX.EM 12/19
ANY AND ALL STATEMENTS MADE ON THIS APPLICATION OR MADE IN CONNECTION WITH IT, INCLUDING ANY
ATTACHMENTS OR AMENDMENTS, ARE SUBJECT TO VERIFICATION.
10. VETERANS CREDITS: To claim additional credit as an honorably discharged veteran, you must check the appropriate box below and answer questions A-D.
(You must request, complete and return a separate Application for Veteran’s Credit and proof of eligibility by the date indicated on the form.)
 NO
 NON-DISABLED VETERAN - A member of the Armed Forces of the U.S. who served in time of war as defined by Civil Service Law and who was honorably
discharged or released under honorable circumstances from such service.
DISABLED VETERAN - A veteran who is certified by the U.S. Veterans Administration as entitled to receive disability payments upon the certification of such
Veteran’s Administration for at least 10% disability incurred by him in time of war and is in existence at the time of application.
CURRENTLY ON ACTIVE DUTY - On active duty (other than for training purposes) in the Armed Forces of the United States.
A. Have you ever served in the Armed Forces of the United States? (The “Armed Forces of the United States” means the Army, Navy, Marine YES NO
Corps, Air Force or Coast Guard, including all components thereof and the National Guard when in the services 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.)
YES NO
B. If “YES” did you receive a discharge which was honorable or were you released under honorable circumstances? 
C. Did you ever serve in the Armed Forces of the U.S. during any of the following periods?
Apr 6, 1917-Nov 11, 1918; Dec 7, 1941-Dec 31, 1946; June 27, 1950-Jan 31, 1955; Feb 28, 1961-May 7, 1975; Persian Gulf conflict from YES NO
Aug 2, 1990-to the end of such hostilities; Commissioned corps of the US Public Health Services-July 29, 1945-Sep 2, 1945; June 26, 1950- 
July 3, 1952; or to receive credit for the following periods, you must have received the armed forces, navy or marine corps expeditionary medal:
Hostilities in Lebanon: June 1, 1983-Dec 1, 1987; Hostilities in Grenada: Oct 23, 1983-Nov 21, 1983; Hostilities
in Panama: Dec 20, 1989-Jan 31,1990.
D. Since January 1, 1951, have you used additional credits as a disabled or non-disabled veteran for permanent appointment to any YES NO
position in the public employment of New York State or any of its civil divisions?

11. EDUCATION: If the minimum qualifications for this position requires a college degree or college credit, you must submit a copy of your official academic transcript
with this application.
Have you graduated from high school or do you have a high school equivalency diploma or high school individual education plan diploma? YES  NO
If Yes: Name and Location of High School __________________________________________ or
Issuing Governmental Authority_____________________________________________ Date of Issue _____________
Name of School
and City and
State in which
located
Dates of Attendance
(Month and Year)
From To
Day
Or
Night
Full
Or
Part
Time
No. of
Years
Credited
Type of Course
or
Major Subject
Number of
College
Credits
Received
Type of
Degree
Receive
d
Date Degree
Expected or
Received
College, University,
Professional or
Technical School
Other Schools or
Special Courses
12. LICENSES If the minimum qualifications for this position require a license, certificate or other authorization to practice a trade or profession, complete the following
question and include a copy of your license. If not currently licensed check this box  (INCLUDE A COPY OF YOUR LICENSE)
Name of Trade or Profession License Number Granted by (licensing agency) City or State of
Specialty Date License First Issued Registered From: (Mo./Yr.) To: (Mo./Yr.)
13. If required, do you have a valid license to operate a motor vehicle in New York State? YES NO
14. Have you ever worked for the County under a different name? YES  NO If yes, list different name and explain:
15. Name(s) of relative currently employed by the County___________________________________________________________________________________________
16. Have you ever taken any civil service exams given by this department or any other civil service agency (including NYS)? YES NO If “YES” give titles and dates:
TITLE OF EXAMINATION: DATE: TITLE OF EXAMINATION: DATE:
________________________________________________________ ____________________________________________________________
________________________________________________________ ____________________________________________________________
17. PERFORMANCE TEST: If the examination you are filing for requires a performance test, refer to the section WAIVER OF PERFORMANCE TEST on the examination
announcement for waiver criteria and a description of acceptable documentation. Are you eligible for and requesting a waiver of the performance test? YES NO
(If yes, you must request, complete and return the Performance Test Waiver form by the date indicated on it.)
(3) APP/EX.EM 12/19
ANY AND ALL STATEMENTS MADE ON THIS APPLICATION OR MADE IN CONNECTION WITH IT, INCLUDING ANY ATTACHMENTS OR
AMENDMENTS, ARE SUBJECT TO VERIFICATION.
18. DESCRIPTION OF EXPERIENCE You are responsible for submitting an accurate, adequate and clear description of your experience. Omissions or vagueness will
NOT be interpreted in your favor.
Beginning with the most recent, describe below in detail all employment that is pertinent to the position applied for. Under “Duties” describe the nature of the work
personally performed by you, with estimated percentages of time spent on each type of work. If your title or duties changed materially in the course of your
tenure in any one organization, indicate such change clearly and as a separate employment. State size and kind of working force, if any, supervised by you and
the extent of such supervision. If the examination announcement states that volunteer or unpaid experience is acceptable as qualifying, describe it in the same way as
paid work, showing it as unpaid in the “Earnings” box. If you have had military service which includes experience pertinent to the position(s), describe such experience
as a separate employment. (If more space is needed, attach 8½” X 11” sheets of paper.)
LENGTH OF EMPLOYMENT FIRM NAME: STREET ADDRESS CITY STATE ZIP
MO YR MO YR
FROM / TO / TELEPHONE NO.:
EARNINGS (Check one) DESCRIBE DUTIES WITH ESTIMATED PERCENTAGES OF TIME SPENT ON EACH TYPE OF WORK (TOTAL NOT TO EXCEED 100%)
PAID OR UNPAID
TYPE OF BUSINESS
YOUR EXACT TITLE
NAME OF SUPERVISOR
SUPERVISOR’S TITLE
No. of hours worked per week:
(exclusive of overtime) Reason for Leaving:
LENGTH OF EMPLOYMENT FIRM NAME: STREET ADDRESS CITY STATE ZIP
MO YR MO YR
FROM / TO / TELEPHONE NO.:
EARNINGS (Check one) DESCRIBE DUTIES WITH ESTIMATED PERCENTAGES OF TIME SPENT ON EACH TYPE OF WORK (TOTAL NOT TO EXCEED 100%)
PAID OR UNPAID
TYPE OF BUSINESS
YOUR EXACT TITLE
NAME OF SUPERVISOR
SUPERVISOR’S TITLE
No. of hours worked per week:
(exclusive of overtime) Reason for Leaving:
LENGTH OF EMPLOYMENT FIRM NAME: STREET ADDRESS CITY STATE ZIP
MO YR MO YR
FROM / TO / TELEPHONE NO.:
EARNINGS (Check one) DESCRIBE DUTIES WITH ESTIMATED PERCENTAGES OF TIME SPENT ON EACH TYPE OF WORK (TOTAL NOT TO EXCEED 100%)
PAID OR UNPAID
TYPE OF BUSINESS
YOUR EXACT TITLE
NAME OF SUPERVISOR
SUPERVISOR’S TITLE
No. of hours worked per week:
(exclusive of overtime) Reason for Leaving:
LENGTH OF EMPLOYMENT FIRM NAME: STREET ADDRESS CITY STATE ZIP
MO YR MO YR
FROM / TO / TELEPHONE NO.:
EARNINGS (Check one) DESCRIBE DUTIES WITH ESTIMATED PERCENTAGES OF TIME SPENT ON EACH TYPE OF WORK (TOTAL NOT TO EXCEED 100%)
PAID OR UNPAID
TYPE OF BUSINESS
YOUR EXACT TITLE
NAME OF SUPERVISOR
SUPERVISOR’S TITLE
No. of hours worked per week:
(exclusive of overtime) Reason for Leaving:
SPECIAL INSTRUCTIONS AND INFORMATION FOR CANDIDATES FOR EXAMINATION
(4) APP/EX.EM 12/19
A. ANNOUNCEMENT OF EXAMINATION
Before filling out your application, you must read the announcement for this
examination thoroughly and carefully.
When completing your application be sure to enter, at the top of page 1, the
examination number and title which identifies the examination for which you are
filing and submit it to the Personnel Department along with the processing fee.
B. ADMISSION TO EXAMINATION
Do not interpret a notice to appear for, or actual participation in the
examination, to mean that you have been found to meet fully the announced
requirements.
Depending on the time available before an examination, applicants may be
admitted, conditionally, to the examination on the basis of statements made on the
application or without prior review of the application. Such statements may not be
reviewed and/or verified until after the examination is held. At that time those
candidates not meeting the requirements will be disqualified and notified of such
disqualification. Those candidates who are subsequently disqualified after taking
the test may NOT be notified of their score.
Contact the Fulton County Personnel Department immediately if you do not
receive a notice within three days of the date of examination informing you
whether or not you are to be admitted to the examination.
C. CHANGE OF ADDRESS
Notify this agency immediately of any change of address. Notification
must be in writing and include the number and title of examination.
D. SPECIAL ARRANGEMENTS
If you have duly filed your application but need special arrangements
because you are a Religious Observer (for religious reasons cannot be tested on
date of examination(s)), a Disabled Person (require special arrangements in order
to participate in the examination(s)), or due to active Military Service deprived of
participation on the scheduled date, you must
1. Check the appropriate box in Question 4 and indicate the special
arrangements you require in the REMARKS section below.
2. Write to the Fulton County Personnel Department no later than the last
date of filing for this examination. Your request must include examination number
and title and the type of special arrangements required.
E. BACKGROUND INVESTIGATION
Applicants may be required to undergo a State and national criminal history
background investigation, which will include a fingerprint check, to determine
suitability for appointment. Failure to meet the standards for the background
investigation may result in disqualification.
F. VETERANS CREDITS
If you are making a claim for veterans’ credits with this application, be sure
you read the following information very carefully: Any claim for additional
credits as a disabled or non-disabled war veteran or candidate currently in the
armed forces, must be made with this application. Failure to complete Question 10
accurately and completely, may result in a denial of your claim.
If you are claiming credits as a disabled war veteran, in addition to meeting
the requirements as indicated by a “YES” answer to question 10 A-C and a “NO”
answer to Question 10 D, you must be certified by the Veterans’ Administration as
being entitled to receive payments for a service-connected disability rate at ten
(10) percent or more, incurred during a “Time of War” as indicated in Question 10
C.
If you have checked the box marked CURRENTLY ON ACTIVE DUTY
for question 10, effective 1/1/98 the NYS Constitution allows candidates currently
serving in the Armed Forces to request conditional veteran's credits. You must
provide acceptable proof of military status, i.e., a military ID card, military orders,
or other official military documents that substantiate active military service at the
time of examination.
If you pass the exam, conditional veteran's credits will be granted only at
the time of establishment of the resulting eligible list. You will be restricted from
certification using the additional credits until you provide appropriate documentary
proof that the service was in time of war (see question 10 C) and that you received
an honorable discharge or were released under honorable circumstances. Until
acceptable documentation is submitted to the Personnel Officer, your name will be
certified with the exam score excluding additional credits.
Veteran's credits may only be used for one governmental permanent
appointment or promotion.
All claims and grants of veterans’ credits are tentative and must be verified
through inspection of discharge papers and other related documents, as necessary,
prior to the establishment of the eligible list. All statements you make in support
of your claim for additional credits are subject to investigation and substantiation
by this agency. In the event of subsequent disclosure of any material mis-
statement or fraud in this claim, your appointment may be rescinded and you may
be disqualified from further appointment on which you have been granted
additional credits as a result of such material mis-statement or fraud.
THE NEW YORK STATE HUMAN RIGHTS LAW PROHIBITS
DISCRIMINATION IN EMPLOYMENT BECAUSE OF AGE, RACE,
CREED, COLOR, NATIONAL ORIGIN, SEX, DISABILITY, MARITAL
STATUS, OR CRIMINAL RECORD. 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, SEX, DISABILITY, MARITAL STATUS OR CRIMINAL
RECORD IN CONNECTION WITH EMPLOYMENT.
ANY AND ALL STATEMENTS MADE ON THIS APPLICATION OR MADE IN CONNECTION WITH IT, INCLUDING ANY
ATTACHMENTS OR AMENDMENTS, ARE SUBJECT TO VERIFICATION.
REMARKS: (Use this space to provide any additional information, as necessary. If more space is required, attach additional 8½”X11” sheets)
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FULTON COUNTY PERSONNEL DEPARTMENT (County of Fulton)

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Completed 6 August 2020

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