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C. Personal Privacy Protection Law Notification
The information you are providing will be used to determine your eligibility to participate in the Telecommuting
Pilot Program. This information will be retained by your agency. Failure to provide the requested information
may result in a delay in processing or denial of your application.
It is the responsibility and the intent of the State of New York to fully comply with the provisions of article 6-A of
the Public Officer’s Law, the Personal Privacy Protection Law. The Personal Privacy Law protects you from the
random collection of personal information by state agencies. The law enables you to access and/or correct
information on file which pertains to you. It also regulates disclosure of personal information to persons
authorized by law to have access for official use.
I am in receipt of, have read and agree to adhere to the Telecommuting Pilot Program Bulletin, my
agency/campus employee handbook and the following additional policies if any (to be completed by
By entering your name, you are signing this document and agree to abide by all rules and guidelines.
Employee Name Date
*Submit the application to your supervisor for review.