Form MSD 330
Leave this space blank Allegany County is an Affirmative Action / Equal Opportunity Employer Leave this space blank
Date Received Checked by
CIVIL SERVICE APPLICATION
ALLEGANY COUNTY DEPARTMENT OF CIVIL SERVICE
7 COURT STREET
COUNTY OFFICE BUILDING
BELMONT, NEW YORK 14813-1081
NUMBER AND EXACT TITLE OF EXAM AS STATED ON THE ANNOUNCEMENT
This application is part of your examination. Answer all questions fully. Some questions can be answered with an “X” in the box which applies to you. Attach additional sheets if
necessary in order to give complete and detailed information.
1. FULL NAME Sex M F
Last Name First Name Initial
Street Address or RD or PO Box
City/Town State Zip Code
IMMEDIATE NOTICE SHOULD BE GIVEN OF ANY CHANGE IN POST OFFICE ADDRESS
BEFORE OR AFTER EXAMINATION
2. PHONE: Home Cell
EMAIL:
3. SOCIAL SECURITY NUMBER
4. Do you have the legal right to reside and accept employment YES NO
in the United States?
5. RESIDENCE
Jurisdiction of legal residence for previous month:
State County
City or Village School District
6. Check below if you desire special arrangements because you are a:
Sabbath Observer (For religious reasons cannot be tested on Saturdays)
Handicapped Person (Describe disability on a separate sheet and
indicate type of assistance required)
7. Have you any objections to this department making inquiry regarding your
character and qualification from YES NO
A. Your former employers?
B. Your present employer?
If answer is “YES” to either (A) or (B) explain.
8. Were you ever dismissed from any public employment for disciplinary
reasons? YES NO
If answerer is “YES” give full particulars.
9. If a motor vehicle license is required for the position for which you are
applying, give the following:
Class
Number
Expiration Date
10. Check appropriate box to the right of each question:
A. Were you ever dismissed or discharged form any YES NO
employment for reasons other than lack of work or funds?
B. Did you ever resign from any employment YES NO
rather than face dismissal?
C. Did you ever receive a discharge from the YES NO
Armed Forces of the United States which was
other than “Honorable” or which was issued
under other than honorable circumstances?
D. Have you ever been convicted of any crime YES NO
(felony or misdemeanor)?
E. Are you under charges for any crime? YES NO
F. Have you ever forfeited bail bond posted YES NO
to guarantee your appearance in court to
answer to any criminal charge?
If you answered “YES” to any of the questions 10A-F above, you may give
specifics on a separate sheet. If you elect not to provide specifics, however,
or if such explanation is insufficient, a confidential investigation supplement
may be sent to you.
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.
THE NEW YOUR STATE HUMAN RIGHTS LAW PROHIBITS DISCRIMINATION IN
EMPLOYMENT BECAUSE OF AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, SEX,
DISABILITY, MARTIAL STATUS, OR CIMINAL 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, MARTIAL STATUS, OR CIMINAL
RECORD IN CONNECTION WITH EMPLOYMENT BY ALLEGANY COUNTY
MUNICIPALITIES.
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.
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
(MUST BE ORIGINIAL SIGNATURE) Date
Indicate any other surname (last name) by which you are or have been
known. (Please print)
Police Officer Applicants Only
Date of Birth
ALL STATEMENTS ARE SUBJECT TO VERIFICATION
Approved
Conditional
Disapproved
