Application Form for Examination or Employment - Ontario County, New York

The New York State Department of Public Service has released this version of the "Application Form for Examination or Employment" on December 1, 2010.

This form may be used by all New York residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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ONTARIO COUNTY APPLICATION FOR EXAMINATION OR EMPLOYMENT
MAIL OR DELIVER TO:
ONTARIO COUNTY DEPARTMENT OF HUMAN RESOURCES • 3019 COUNTY COMPLEX DRIVE • CANANDAIGUA • NEW YORK 14424
www.co.ontario.ny.us/humanresources
TYPE OR PRINT CLEARLY IN INK all parts of this application.
1. _________________________________________________________________________________________________________________________________________________
JOB/EXAM TITLE
2. NAME AND ADDRESS: IMMEDIATE notice should be given for any change in item #2.
/
/
__________________________________________________________________________________________________________________________________________________
LAST
FIRST
MIDDLE
SOCIAL SECURITY #
Indicate any other surname (last name) by which you are or have been known ____________________________________________________________________________________
LEGAL MAILING ADDRESS _____________________________________________________ LEGAL RESIDENCE ____________________________________________________
CITY ______________________________________________________ STATE __________________________________ ZIP CODE ____________________________________
HOME PHONE NO. (
) ______________________ CELL PHONE NO. (
) _______________________ BUSINESS PHONE NO. (
) _________________________
SCHOOL DISTRICT _______________________________________________________________________________ YEAR/MONTHS ____________________________________
TOWN ________________________ , VILLAGE __________________________ OR CITY _____________________ YEAR/MONTHS ____________________________________
COUNTY ________________________________________________________________________________________ YEAR/MONTHS ____________________________________
3. VETERANS’ CREDIT (IF APPLICABLE, CHECK ONE)
VETERAN
DISABLED VETERAN
CURRENTLY ACTIVE
Currently active military personnel may apply for conditional credit pending honorable discharge. Disabled and non-disabled veterans who establish eligibility for additional credits and are
successful in the examination are entitled to have 10 and 5 points respectively (5 and 2.5 points of credits for PROMOTIONAL Examination), added to their earned scores provided that
they have not used credits to obtain permanent appointment or promotion subsequent to January 1, 1951. You will be allowed the option of waiving these credits after the completion
of the examination.
Check appropriate box to right of each question:
*Credit for Lebanon, Grenada, and Panama will be limited to those who
YES
NO
YES
NO
A.
Did you serve in the Armed Forces of the United
received the Armed Forces Expeditionary Medal, the Navy Expeditionary
States during any of the following periods?
Medal, or the Marine Corps Expeditionary Medal. The DD214 form which
December 7, 1941 to December 31, 1946; June 27, 1950
has always been required to verify military service should also contain
to January 31,1955; February 28, 1961 to May 7, 1975;
verification of possession of Expeditionary Medals for Lebanon, Grenada, or
U.S. Public Health Service: July 29, 1945 to September
Panama.
3, 1945 or June 25, 1950 to July 4, 1952. *Lebanon -
B.
Are you currently a resident of New York State?
June 1, 1983 to December 1, 1987. *Grenada - October
23, 1983 to November 21,1983. *Panama - December
C.
Since January 1, 1951, have you used additional credits as a disabled
20, 1989 to January 31, 1990. Persian Gulf - August
or non-disabled veteran for appointment to any position in the public
2, 1990 through the date upon which hostilities end.
employment of New York State or any of its civil divisions?
Did you ever receive a discharge from the Armed Forces of the United States which was other than “Honorable” or which was issued under other than honorable
conditions?
4. INDICATE ANSWER BY PLACING AN ”X” IN THE APPROPRIATE SPACE.
A.
Were you ever dismissed from any employment except for lack of work or funds, disability or medical condition? ..................................................................... YES
NO
B.
Did you ever resign from any employment rather than face discharge? ........................................................................................................................................ YES
NO
C.
Are you now under charges for any crime? ..................................................................................................................................................................................... YES
NO
D.
CONVICTION
Have you ever been convicted of any crime (felony or misdemeanor)? .......................................................................................................... YES
NO
F.
CONVICTION
If yes, explain in #5. Give for each case: 1) Charge, 2) Place, 3) Date, 4) Action taken
You may omit:
1. Parking violations.
2..
Any offense which was adjudicated in a juvenile court or under a youthful offender law.
Convictions will not necessarily disqualify you. What you were convicted of and how long ago is important. Each case is evaluated in relation to the
duties and responsibilities of the position for which you have applied.
5. USE THIS SPACE FOR ANY EXPLANATIONS. (Attach additional sheets if more space is needed
__________________________________________________________________________________________________________________________________________________
6.
A.
Do you have a legal right to reside and accept employment in the United States?
YES
NO
B.
CITIZENSHIP: Are you a citizen of the United States?
YES
NO
C.
If minimum and/or maximum age limits are established for the position applied for, enter your date of birth here ______________________________ .
D.
Sibling of Fire Fighter or Police Officer lost in 9/11/01?
YES
NO
E.
Child of Fire Fighter or Police Officer lost in line of duty?
YES
NO
7. EMPLOYMENT PREFERENCES: ( applies to all exams/jobs) In addition to full time,
I will accept part-time
I will accept temporary
I will accept work at the following agencies:
COUNTY
CITIES
VILLAGES
TOWNS
SCHOOL DISTRICTS
FLCC
Shift Work: I will work evenings and/or nights.
YES
NO
8. Do you need special arrangements for this exam (Religious Accommodation or disabled)? If yes, explain in #5 ...................................................................... YES
NO
DECLARATION (This affirmation must be signed and dated.)
I understand that false statements made herein are punishable as a Class A Misdemeanor, pursuant to Section 210.45 of the Penal Law of the State of New York. I declare that, subject
to the penalties of perjury, any statements made on this application and any attachments are the truth and to the best of my knowledge correct.
SIGNATURE
________________________________________________________________________
DATE __________________________________________
HUMAN RESOURCES USE ONLY
APPROVED
PENDING
CONDITIONAL
DISAPPROVED
COMMENTS ________________________________________________________________ CHECK # ____________________ DATE _____________________________
WV D
Methods Research Questionnaire (Optional)
Guaranteed Education Loan Questionnaire
The CONFIDENTIAL and VOLUNTARY reply will be used to evaluate recruitment, examination
and testing methods. This reply will in no way affect your participation in this or future Civil
Section 50-b of the New York State Civil Service Law REQUIRES that all applicants
Service examinations. This information is for research purposes only.
for examination be asked the following questions:
1. Have you any loans made or guaranteed by the New York State Higher Education
1. Birth date * ____________________________________
Services Corporation which are currently outstanding?
YES
NO
2. Disabled?*
YES
NO
3. Check only one box which identifies your group.*
2. If so, are you presently in default on any such loan?
YES
NO
MALE
FEMALE
Name
_________________________________________________________
White
Black
Hispanic
Asian American
American Indian
Address
_________________________________________________________
4. How did you learn about this job?
City, State, Zip _____________________________________________________
Ontario County Personnel
Internet
NYS Employment Office
Exam # and Title ___________________________________________________
Private Employment Office
Community Organization
Newspaper ____________________________
Relative/Friend
THIS AFFIRMATION MUST BE COMPLETED. I affirm, under penalty of perjury,
Title
that all statements made above are true
Government Employee
Radio and/or Television
_________________________________________________________________
*New York State Law prohibits discrimination because of age, race, color, creed, sex, national
Signature
Date
origin, sexual orientation, military status, predisposing genetic characteristics, marital status,
domestic violence victim status or disabilities and, in certain circumstances, conviction record.
ONTARIO COUNTY ~ AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
_
ONTARIO COUNTY APPLICATION FOR EXAMINATION OR EMPLOYMENT
MAIL OR DELIVER TO:
ONTARIO COUNTY DEPARTMENT OF HUMAN RESOURCES • 3019 COUNTY COMPLEX DRIVE • CANANDAIGUA • NEW YORK 14424
www.co.ontario.ny.us/humanresources
TYPE OR PRINT CLEARLY IN INK all parts of this application.
1. _________________________________________________________________________________________________________________________________________________
JOB/EXAM TITLE
2. NAME AND ADDRESS: IMMEDIATE notice should be given for any change in item #2.
/
/
__________________________________________________________________________________________________________________________________________________
LAST
FIRST
MIDDLE
SOCIAL SECURITY #
Indicate any other surname (last name) by which you are or have been known ____________________________________________________________________________________
LEGAL MAILING ADDRESS _____________________________________________________ LEGAL RESIDENCE ____________________________________________________
CITY ______________________________________________________ STATE __________________________________ ZIP CODE ____________________________________
HOME PHONE NO. (
) ______________________ CELL PHONE NO. (
) _______________________ BUSINESS PHONE NO. (
) _________________________
SCHOOL DISTRICT _______________________________________________________________________________ YEAR/MONTHS ____________________________________
TOWN ________________________ , VILLAGE __________________________ OR CITY _____________________ YEAR/MONTHS ____________________________________
COUNTY ________________________________________________________________________________________ YEAR/MONTHS ____________________________________
3. VETERANS’ CREDIT (IF APPLICABLE, CHECK ONE)
VETERAN
DISABLED VETERAN
CURRENTLY ACTIVE
Currently active military personnel may apply for conditional credit pending honorable discharge. Disabled and non-disabled veterans who establish eligibility for additional credits and are
successful in the examination are entitled to have 10 and 5 points respectively (5 and 2.5 points of credits for PROMOTIONAL Examination), added to their earned scores provided that
they have not used credits to obtain permanent appointment or promotion subsequent to January 1, 1951. You will be allowed the option of waiving these credits after the completion
of the examination.
Check appropriate box to right of each question:
*Credit for Lebanon, Grenada, and Panama will be limited to those who
YES
NO
YES
NO
A.
Did you serve in the Armed Forces of the United
received the Armed Forces Expeditionary Medal, the Navy Expeditionary
States during any of the following periods?
Medal, or the Marine Corps Expeditionary Medal. The DD214 form which
December 7, 1941 to December 31, 1946; June 27, 1950
has always been required to verify military service should also contain
to January 31,1955; February 28, 1961 to May 7, 1975;
verification of possession of Expeditionary Medals for Lebanon, Grenada, or
U.S. Public Health Service: July 29, 1945 to September
Panama.
3, 1945 or June 25, 1950 to July 4, 1952. *Lebanon -
B.
Are you currently a resident of New York State?
June 1, 1983 to December 1, 1987. *Grenada - October
23, 1983 to November 21,1983. *Panama - December
C.
Since January 1, 1951, have you used additional credits as a disabled
20, 1989 to January 31, 1990. Persian Gulf - August
or non-disabled veteran for appointment to any position in the public
2, 1990 through the date upon which hostilities end.
employment of New York State or any of its civil divisions?
Did you ever receive a discharge from the Armed Forces of the United States which was other than “Honorable” or which was issued under other than honorable
conditions?
4. INDICATE ANSWER BY PLACING AN ”X” IN THE APPROPRIATE SPACE.
A.
Were you ever dismissed from any employment except for lack of work or funds, disability or medical condition? ..................................................................... YES
NO
B.
Did you ever resign from any employment rather than face discharge? ........................................................................................................................................ YES
NO
C.
Are you now under charges for any crime? ..................................................................................................................................................................................... YES
NO
D.
CONVICTION
Have you ever been convicted of any crime (felony or misdemeanor)? .......................................................................................................... YES
NO
F.
CONVICTION
If yes, explain in #5. Give for each case: 1) Charge, 2) Place, 3) Date, 4) Action taken
You may omit:
1. Parking violations.
2..
Any offense which was adjudicated in a juvenile court or under a youthful offender law.
Convictions will not necessarily disqualify you. What you were convicted of and how long ago is important. Each case is evaluated in relation to the
duties and responsibilities of the position for which you have applied.
5. USE THIS SPACE FOR ANY EXPLANATIONS. (Attach additional sheets if more space is needed
__________________________________________________________________________________________________________________________________________________
6.
A.
Do you have a legal right to reside and accept employment in the United States?
YES
NO
B.
CITIZENSHIP: Are you a citizen of the United States?
YES
NO
C.
If minimum and/or maximum age limits are established for the position applied for, enter your date of birth here ______________________________ .
D.
Sibling of Fire Fighter or Police Officer lost in 9/11/01?
YES
NO
E.
Child of Fire Fighter or Police Officer lost in line of duty?
YES
NO
7. EMPLOYMENT PREFERENCES: ( applies to all exams/jobs) In addition to full time,
I will accept part-time
I will accept temporary
I will accept work at the following agencies:
COUNTY
CITIES
VILLAGES
TOWNS
SCHOOL DISTRICTS
FLCC
Shift Work: I will work evenings and/or nights.
YES
NO
8. Do you need special arrangements for this exam (Religious Accommodation or disabled)? If yes, explain in #5 ...................................................................... YES
NO
DECLARATION (This affirmation must be signed and dated.)
I understand that false statements made herein are punishable as a Class A Misdemeanor, pursuant to Section 210.45 of the Penal Law of the State of New York. I declare that, subject
to the penalties of perjury, any statements made on this application and any attachments are the truth and to the best of my knowledge correct.
SIGNATURE
________________________________________________________________________
DATE __________________________________________
HUMAN RESOURCES USE ONLY
APPROVED
PENDING
CONDITIONAL
DISAPPROVED
COMMENTS ________________________________________________________________ CHECK # ____________________ DATE _____________________________
WV D
Methods Research Questionnaire (Optional)
Guaranteed Education Loan Questionnaire
The CONFIDENTIAL and VOLUNTARY reply will be used to evaluate recruitment, examination
and testing methods. This reply will in no way affect your participation in this or future Civil
Section 50-b of the New York State Civil Service Law REQUIRES that all applicants
Service examinations. This information is for research purposes only.
for examination be asked the following questions:
1. Have you any loans made or guaranteed by the New York State Higher Education
1. Birth date * ____________________________________
Services Corporation which are currently outstanding?
YES
NO
2. Disabled?*
YES
NO
3. Check only one box which identifies your group.*
2. If so, are you presently in default on any such loan?
YES
NO
MALE
FEMALE
Name
_________________________________________________________
White
Black
Hispanic
Asian American
American Indian
Address
_________________________________________________________
4. How did you learn about this job?
City, State, Zip _____________________________________________________
Ontario County Personnel
Internet
NYS Employment Office
Exam # and Title ___________________________________________________
Private Employment Office
Community Organization
Newspaper ____________________________
Relative/Friend
THIS AFFIRMATION MUST BE COMPLETED. I affirm, under penalty of perjury,
Title
that all statements made above are true
Government Employee
Radio and/or Television
_________________________________________________________________
*New York State Law prohibits discrimination because of age, race, color, creed, sex, national
Signature
Date
origin, sexual orientation, military status, predisposing genetic characteristics, marital status,
domestic violence victim status or disabilities and, in certain circumstances, conviction record.
ONTARIO COUNTY ~ AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
9A. EDUCATION If more space is needed, attach additional sheets.
Type of School
Name of School and Location
Years
College Credits
Type of Degree
Graduated?
Major Course of Studies
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Completed
Received
Received
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
High School or
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Equivalency
3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Diploma Number
YES
NO
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
College, University,
Professional or
Technical School
YES
NO
Other Schools
or
YES
NO
Special Courses
9B. EDUCATION: Degree received? ______ YES
______ NO If YES, was degree received within last 5 years? ______ YES
______ NO If NO, when do you expect receipt
of degree? ________________________
10. LICENSE Do you possess a license to practice a trade or profession?
YES
NO
(Complete only if the position for which you are applying requires one.)
Name of trade or profession _______________________________________________ License/Certificate Number _______________________________________________
Licensing Agency _______________________________________________________ City/State ______________________________________________________________
Original date of issue ____________________________________________________ Date of expiration _______________________________________________________
11. DRIVER’S LICENSE (Complete only if the position for which you are applying requires one.) State of licensure ____________
Endorsements _______________________
Number ____________________ Class of license _________________________ Date of expiration ________________ Restrictions ________________________________
12. EXPERIENCE: YOU MUST COMPLETE THIS SECTION WHETHER YOU SUBMIT A RESUME’ OR NOT. 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 workforce, if any, supervised by you and the extent of such supervision. DESCRIBE IN DETAIL, beginning
with your most recent employment and working backwards to your first, any employment 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 military service. Applicants may be required to furnish proof of all experience claimed. COMPLETE ALL
SECTIONS.
IF MORE SPACE IS NEEDED, ATTACH ADDITIONAL SHEETS AT TOP OF PAGE.
Length of Employment
Firm Name
Address
City and State
From: Mo.
Yr.
Type of Business
Your Title
Name and Title of Your Supervisor
To:
Mo.
Yr.
Yrs.
Mos.
Duties:
Salary:
Hours per week:
Reason for leaving:
Length of Employment
Firm Name
Address
City and State
From: Mo.
Yr.
Type of Business
Your Title
Name and Title of Your Supervisor
To:
Mo.
Yr.
Yrs.
Mos.
Duties:
Salary:
Hours per week:
Reason for leaving:
Length of Employment
Firm Name
Address
City and State
From: Mo.
Yr.
Type of Business
Your Title
Name and Title of Your Supervisor
To:
Mo.
Yr.
Yrs.
Mos.
Duties:
Salary:
Hours per week:
Reason for leaving:
Length of Employment
Firm Name
Address
City and State
From: Mo.
Yr.
Type of Business
Your Title
Name and Title of Your Supervisor
To:
Mo.
Yr.
Yrs.
Mos.
Duties:
Salary:
Hours per week:
Reason for leaving:
ONTARIO COUNTY ~ AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Rev. 12/10
THE NEW YORK STATE HUMAN RIGHTS LAW PROHIBITS DISCRIMINATION IN EMPLOYMENT BECAUSE OF AGE, RACE, COLOR, CREED, SEX, NATIONAL ORIGIN, SEXUAL
ORIENTATION, MILITARY STATUS, PREDISPOSING GENETIC CHARACTERISTICS, MARITAL STATUS, DOMESTIC VIOLENCE VICTIM STATUS OR DISABILITIES AND, IN
CERTAIN CIRCUMSTANCES PURSUANT TO EXECUTIVE LAW 296, CONVICTION RECORD. ACCORDINGLY, NOTHING IN THIS APPLICATION FORM SHOULD BE VIEWED AS
EXPRESSING DIRECTLY OR INDIRECTLY, ANY LIMITATION, SPECIFICATION, OR DISCRIMINATION AS TO AGE, RACE, COLOR, CREED, SEX, NATIONAL ORIGIN, SEXUAL
ORIENTATION, MILITARY STATUS, PREDISPOSING GENETIC CHARACTERISTICS, MARITAL STATUS, DOMESTIC VIOLENCE VICTIM STATUS OR DISABILITIES AND, IN
CERTAIN CIRCUMSTANCES PURSUANT TO EXECUTIVE LAW 296, CONVICTION RECORD IN CONNECTION WITH EMPLOYMENT BY THE COUNTY OF ONTARIO.

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