Form MSD330 "Civil Service Application" - ALLEGANY COUNTY, New York

What Is Form MSD330?

This is a legal form that was released by the Department of Civil Service - Allegany County, New York - a government authority operating within New York. The form may be used strictly within ALLEGANY COUNTY. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Department of Civil Service - Allegany County, New York;
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Download a fillable version of Form MSD330 by clicking the link below or browse more documents and templates provided by the Department of Civil Service - Allegany County, New York.

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Download Form MSD330 "Civil Service Application" - ALLEGANY COUNTY, New York

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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
ed
Approv
BELMONT, NEW YORK 14813-1081
Conditional
Disapproved
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
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?
Last Name
First Name
Initial
B. Did you ever resign from any employment
YES NO
rather than face dismissal?
Street Address or RD or PO Box
C. Did you ever receive a discharge from the
YES NO
Armed Forces of the United States which was
City/Town
State
Zip Code
other than “Honorable” or which was issued
under other than honorable circumstances?
IMMEDIATE NOTICE SHOULD BE GIVEN OF ANY CHANGE IN POST OFFICE ADDRESS
BEFORE OR AFTER EXAMINATION
D. Have you ever been convicted of any crime
YES NO
2. PHONE: Home
Cell
(felony or misdemeanor)?
EMAIL:
E. Are you under charges for any crime?
YES NO
3. SOCIAL SECURITY NUMBER
F. Have you ever forfeited bail bond posted
YES NO
4. Do you have the legal right to reside and accept employment
YES NO
to guarantee your appearance in court to
in the United States?
answer to any criminal charge?
5. RESIDENCE
Jurisdiction of legal residence for previous month:
State
County
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,
City or Village
School District
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.
6. Check below if you desire special arrangements because you are a:
Each case is considered and evaluated on individual merits in relation to the
Sabbath Observer
(For religious reasons cannot be tested on Saturdays)
duties and responsibilities of the position(s) for which you are applying.
Handicapped Person (Describe disability on a separate sheet and
indicate type of assistance required)
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
7. Have you any objections to this department making inquiry regarding your
THIS APPLICATION FORM SHOULD BE VIEWED AS EXPRESSING, DIRECTLY OR
character and qualification from
YES NO
INDIRECTLY, ANY LIMITATION, SPECIFICATION, OR DISCRIMINATION AS TO AGE, RACE,
A. Your former employers?
CREED, COLOR, NATIONAL ORIGIN, SEX, DISABILITY, MARTIAL STATUS, OR CIMINAL
B. Your present employer?
RECORD IN CONNECTION WITH EMPLOYMENT BY ALLEGANY COUNTY
MUNICIPALITIES.
If answer is “YES” to either (A) or (B) explain.
NOTE: When filling out your application form, check to make sure that all
8. Were you ever dismissed from any public employment for disciplinary
questions have been answered. An incomplete application may result in its
reasons?
YES NO
disapproval.
If answerer is “YES” give full particulars.
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.
9. If a motor vehicle license is required for the position for which you are
applying, give the following:
Signature of Applicant
Date
(MUST BE ORIGINIAL SIGNATURE)
Class
Indicate any other surname (last name) by which you are or have been
known. (Please print)
Number
Police Officer Applicants Only
Expiration Date
Date of Birth
ALL STATEMENTS ARE SUBJECT TO VERIFICATION
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
ed
Approv
BELMONT, NEW YORK 14813-1081
Conditional
Disapproved
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
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?
Last Name
First Name
Initial
B. Did you ever resign from any employment
YES NO
rather than face dismissal?
Street Address or RD or PO Box
C. Did you ever receive a discharge from the
YES NO
Armed Forces of the United States which was
City/Town
State
Zip Code
other than “Honorable” or which was issued
under other than honorable circumstances?
IMMEDIATE NOTICE SHOULD BE GIVEN OF ANY CHANGE IN POST OFFICE ADDRESS
BEFORE OR AFTER EXAMINATION
D. Have you ever been convicted of any crime
YES NO
2. PHONE: Home
Cell
(felony or misdemeanor)?
EMAIL:
E. Are you under charges for any crime?
YES NO
3. SOCIAL SECURITY NUMBER
F. Have you ever forfeited bail bond posted
YES NO
4. Do you have the legal right to reside and accept employment
YES NO
to guarantee your appearance in court to
in the United States?
answer to any criminal charge?
5. RESIDENCE
Jurisdiction of legal residence for previous month:
State
County
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,
City or Village
School District
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.
6. Check below if you desire special arrangements because you are a:
Each case is considered and evaluated on individual merits in relation to the
Sabbath Observer
(For religious reasons cannot be tested on Saturdays)
duties and responsibilities of the position(s) for which you are applying.
Handicapped Person (Describe disability on a separate sheet and
indicate type of assistance required)
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
7. Have you any objections to this department making inquiry regarding your
THIS APPLICATION FORM SHOULD BE VIEWED AS EXPRESSING, DIRECTLY OR
character and qualification from
YES NO
INDIRECTLY, ANY LIMITATION, SPECIFICATION, OR DISCRIMINATION AS TO AGE, RACE,
A. Your former employers?
CREED, COLOR, NATIONAL ORIGIN, SEX, DISABILITY, MARTIAL STATUS, OR CIMINAL
B. Your present employer?
RECORD IN CONNECTION WITH EMPLOYMENT BY ALLEGANY COUNTY
MUNICIPALITIES.
If answer is “YES” to either (A) or (B) explain.
NOTE: When filling out your application form, check to make sure that all
8. Were you ever dismissed from any public employment for disciplinary
questions have been answered. An incomplete application may result in its
reasons?
YES NO
disapproval.
If answerer is “YES” give full particulars.
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.
9. If a motor vehicle license is required for the position for which you are
applying, give the following:
Signature of Applicant
Date
(MUST BE ORIGINIAL SIGNATURE)
Class
Indicate any other surname (last name) by which you are or have been
known. (Please print)
Number
Police Officer Applicants Only
Expiration Date
Date of Birth
ALL STATEMENTS ARE SUBJECT TO VERIFICATION
11.SERVICE IN ARMED FORCES
YES NO
12. VETERANS’ CREDITS
Do you draw additional credits on the exam as an
A. Have you ever served in the armed forces of the U.S.?
honorably discharged veteran?
CHECK ONE
B. If “YES,” have you ever received a discharge from such
YES, as disabled war veteran
YES, as a non-disabled war veteran
forces which was other than honorable?
YES, as a disabled war veteran who previously
If answer is “YES” give full particulars on additional sheet.
used non- disabled war veteran credits
MONTH | DAY | YEAR
NO
C. Date of entry into active service
If “YES” please request and fill out separate form for
D. Date of discharge
veteran’s credits
E. Service serial number
13. LICENSES: If a license, certificate or other authorization to practice a trade or profession is listed as a requirement on the announcement
of the examination(s) for which you are applying, complete the following question: If not currently licensed check this box
Name of Trade or Profession
License Number
Granted by (Licensing Agency)
City or State of
Specialty
Date License First Issued
Registered from:
To
14. EDUCATION: If credit is claimed for a partially completed college curriculum or correspondence course, attach a list of courses and credit or semester
hours completed. Indicate how many credit hours or courses are required for graduation. Do Not send transcript unless required by announcement.
No
If YES, Name and Location of High School
Have you graduated from high school? Yes
If you have a high school equivalency diploma, indicate Issuing Governmental Authority
Number
Date of Issue
Attendance
Type
No. of
Day
Full or
No. of
Did you
Type of
Name of School and
Dates (Month &
Course or
College
Or
Part
Years
graduate
Degree
City in which located
Year)
Major
Credits
Night
Time
Credited
Yes or No
Received
From
To
Subject
Received
College
University
Professional or
Technical School
Other Schools or
Special Courses
15. 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 backward consecutively to your first one.
You may attach a resume. However, attachment of a resume does not satisfy this requirement. Employment used to
Applicants may be required to furnish satisfactory proof of experience claimed.
qualify an applicant for a position/examination must be listed on this application.
Attach additional sheets if needed.
LENGTH OF EMPLOYMENT
Firm Name
Address
City and State
From: Mo
Yr.
Type of Business
Your Title
Name and Title of Immediate Supervisor
To:
Mo
Yr.
DUTIES: Describe the nature of the work personally performed by you, with estimated percentage of time on each type
of work. State size and kind of working force, if any supervised by you and extent of such supervision
Total
Yrs
Mos
MONTHLY SALARY
Min.
Max
Last
Total hrs per WEEK
hrs
Reason For Leaving
LENGTH OF EMPLOYMENT
Firm Name
Address
City and State
From: Mo
Yr.
Type of Business
Your Title
Name and Title of Immediate Supervisor
To:
Mo
Yr.
DUTIES: Describe the nature of the work personally performed by you, with estimated percentage of time on each type
of work. State size and kind of working force, if any supervised by you and extent of such supervision
Total
Yrs
Mos
MONTHLY SALARY
Min.
Max
Last
Total hrs per WEEK
hrs
Reason For Leaving
LENGTH OF EMPLOYMENT
Firm Name
Address
City and State
From: Mo
Yr.
Type of Business
Your Title
Name and Title of Immediate Supervisor
To:
Mo
Yr.
DUTIES: Describe the nature of the work personally performed by you, with estimated percentage of time on each type
of work. State size and kind of working force, if any supervised by you and extent of such supervision
Total
Yrs
Mos
MONTHLY SALARY
Min.
Max
Last
Total hrs per WEEK
hrs
Reason For Leaving
LENGTH OF EMPLOYMENT
Firm Name
Address
City and State
From: Mo
Yr.
Type of Business
Your Title
Name and Title of Immediate Supervisor
To:
Mo
Yr.
DUTIES: Describe the nature of the work personally performed by you, with estimated percentage of time on each type
of work. State size and kind of working force, if any supervised by you and extent of such supervision
Total
Yrs
Mos
MONTHLY SALARY
Min.
Max
Last
Total hrs per WEEK
hrs
Reason For Leaving
LENGTH OF EMPLOYMENT
Firm Name
Address
City and State
From: Mo
Yr.
Type of Business
Your Title
Name and Title of Immediate Supervisor
To:
Mo
Yr.
DUTIES: Describe the nature of the work personally performed by you, with estimated percentage of time on each type
of work. State size and kind of working force, if any supervised by you and extent of such supervision
Total
Yrs
Mos
MONTHLY SALARY
Min.
Max
Last
Total hrs per WEEK
hrs
Reason For Leaving
*You may attach a resume. However, attachment of a resume does not satisfy this requirement. Employment used to qualify an applicant for a position/examination must be
listed on this application.
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