Fillable Form 1.: Essex County Department Of Personnel And

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Form 1.: Essex County Department Of Personnel And

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ESSEX COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER
Essex County Department of Personnel and Civil Service
7551 Court Street, PO Box 217, Elizabethtown NY 12932
Phone: (518) 873-3360 / Fax: (518) 873-3372
APPLICATION FOR EXAMINATION OR EMPLOYMENT
For County, Towns, Villages and School Districts
Please Leave This Space Blank
Number:
Application
Approved:
Conditional:
Disapproved:
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 use
a typewriter. Attach additional sheets if necessary in order to give complete and detailed information.
ALL STATEMENTS ARE SUBJECT TO VERIFICATION.
Name:(Last,First,Middle)
Address:
PO Box and/or Street Town/City State Zip Code:
1.
Phone #:
Immediate Notice should be given if any changes in address before or after examination.
2.
Social Security Number:
3.
Are you under 18? Yes: No:
If so, or if minimum age limits are
established for the position applied
for, enter your date of birth below:
Date of Birth:
School District:
Village or City of:
Town of:
County of:
State of:
Years Months
4. State your actual permanent legal residence and indicate for how long you
have resided there continuously, up to and including date of this
application:
5.
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?
Yes: No:
B. Have you ever been convicted of any crime,
(Felony or Misdemeanor)?
Yes: No:
C. Are you now under any charges for any crime? Yes: No:
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.
6.
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)
Yes: No:
B. If not a U.S. Citizen, do you have a legal right to accept
employment in the United States?
Yes: No:
Please give alien registration number:
C. Are you a retiree from New York State or any civil
division thereof?
Yes: No:
Page 1 of 4
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D. Are you an exempt Volunteer Fireman? Yes: No:
7.
Check appropriate box to the right of each question:
A. Do you have a valid license to operate a motor
vehicle in New York State?
Yes: No:
B. If Yes, please provide the following:
Class: Number: Date of Expiration:
8.
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 Not: Omit Questions 9-13.
9.
If "Yes" did you receive a discharge that was honorable or
were you release under honorable circumstances?
Yes: No:
10.
Have you any objections to this department making inquiry
regarding your character and qualifications?
Yes: No:
11.
Did you serve in active duty in the Armed Forces of the United States
during any of the following periods?
Yes: No:
a.
b.
c.
d.
e.
f.
g.
h.
December 7, 1941 to December 31, 1946;
June 27, 1950 to January 31, 1955;
December 22, 1961 to May 7, 1975
US Public Health Service: July 29, 1945 to September2, 1945 or June 26, 1950 to July 3, 1952;
August 2, 1990 - the date upon which such hostilities end.
Hostilities in Lebanon - June 1, 1983 - December 1, 1987 *
Hostilities in Grenada - October 23, 1983 - November 21, 1983 *
Hostilities in Panama - December 20, 1989 - January 31,1990 *
* denotes - Must have received the armed forces, navy or marine corps expeditionary medal.
12.
Veterans Credits. Do you claim additional credits on this examination as an honorably discharged veteran?
Yes: No:As a disabled war veteran?
Yes: No:As a non-disabled war veteran?
13.
Since January 1, 1951, have you ever used additional credits as a disabled
or non-disabled veteran for appointment to any position in the public
employment of New York State or any of its civil divisions?
Yes: No:
14.
EDUCATION: If credit is claimed for partially completed college curriculum or correspondence course, attach a list of
courses and credits or semester hours completed. Indicate how many credit hours or courses are required for
graduation. DO NOT send transcripts unless required by announcement.
Yes: No:Have you graduated from high school? If yes, give name and location of high school:
If "Yes", give year graduated:
If "No", give highest grade completed:
Yes: No:Have you successfully completed a typing course?
If you have a high school equivalency diploma: Number and/or Date of Issue:
Page 2 of 4
College,
University,
Professional
or Technical
School
College,
University,
Professional
or Technical
School
Name of School
and City in which
it is located
Dates of
Attendance
(Month & Year)
From -To
Day
or
Night
Classes
Full or
Part Time
Number of
Credits
Did you
Graduate
Yes or No
Type of Course
or Major
Number of
College
Credits
Earned
Degree
Received
Date of
Degree
Other
Schools or
Special
Courses
15.
LICENSES: If a license, certificate or other authorization to practice a trade or profession is listed as a requirement on
the announcement or the examination(s) for which you are applying, complete the following:
If not currently licensed, check this box:
Name of Trade or Profession License #: Granted By: City or State:
Specialty Date First Issued: Registered From: To:
EXPERIENCE:
Describe under the headings given below any employment or occupation you have ever had which includes
experience that tends to qualify you for the position sought, and as far as possible, every other employment, including war
service.
Begin with your most recent employment and work back consecutively to your first.
APPLICANTS MAY BE REQUIRED TO FURNISH SATISFACTORY PROOF OF EXPERIENCE CLAIMED.
From:
To:
Totals:
Month: Year:
Length of Employment Firm Name: Address: City / State:
Type of Business: Your Title: Name & Title of Your Supervisor
Monthly Salary:
DUTIES: Describe below the nature of the work performed by you, with estimated percentage of time on each type of work. State
size and kind of working force supervised by you and extent of such supervision (if any).
Min: Max: Last:
Total Hours per Week:
Reason for Leaving:
From:
To:
Totals:
Month: Year:
Length of Employment Firm Name: Address: City / State:
Type of Business: Your Title: Name & Title of Your Supervisor
Monthly Salary:
DUTIES: Describe below the nature of the work performed by you, with estimated percentage of time on each type of work. State
size and kind of working force supervised by you and extent of such supervision (if any).
Min: Max: Last:
Total Hours per Week:
Reason for Leaving:
Page 3 of 4
From:
To:
Totals:
Month: Year:
Length of Employment Firm Name: Address: City / State:
Type of Business: Your Title: Name & Title of Your Supervisor
Monthly Salary:
DUTIES: Describe below the nature of the work performed by you, with estimated percentage of time on each type of work. State
size and kind of working force supervised by you and extent of such supervisor (if any).
Min: Max: Last:
Total Hours per Week:
Reason for Leaving:
From:
To:
Totals:
Month: Year:
Length of Employment Firm Name: Address: City / State:
Type of Business: Your Title: Name & Title of Your Supervisor
Monthly Salary:
DUTIES: Describe below the nature of the work performed by you, with estimated percentage of time on each type of work. State
size and kind of working force supervised by you and extent of such supervision (if any).
Min: Max: Last:
Total Hours per Week:
Reason for Leaving:
IF MORE SPACE IS REQUIRED, USE ADDITIONAL SHEETS ARRANGED IN THE SAME MANNER. ATTACH SUCH SHEETS AT TOP OF PAGE.
NOTE: When filling out your application form, check to make sure that all questions have been answered. An
incomplete application may result in its disapproval. A resume may not be substituted.
THIS AFFIRMATION MUST BE COMPLETED
I affirm that the statements made on this application ( including any attached papers)
are true under the PENALTIES OF PERJURY.
Signature of Applicant
Date:
(Provide any other name you have used in education or employment)
Check box below if you desire special accommodations because you are a:
Sabbath Observer - For religious reasons cannot be tested on Saturdays Yes:
Handicapped Person
Under REMARKS, indicate type of assistance required.
Yes:
REMARKS:
The New York State Human Rights Law prohibits discrimination in employment because of age, race, creed,
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, greed, color, national origin, sex, disability, marital status or criminal record in connection with employment
in the municipal service of the County of Essex.
Page 4 of 4
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Completed 18 July 2020

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