APPLICATION FOR
EXAMINATION OR EMPLOYMENT
Wayne County
FOR OFFICE USE ONLY
Date Received
Civil Service – Personnel Office
26 Church Street, Lyons, New York
14489
Approved
(315) 9467483
Conditional Approval
An Equal Opportunity Employer
Disapproved
Position Title
Examination Number
This application is part of your examination. Answer all questions fully and carefully in ink or by typewriter. Refer to
instructions and Information on page 4. Attach additional sheets if necessary in order to give complete and detailed
information.
1.
NAME, MAILING ADDRESS AND PHONE (Please Print)
Last
First
M.I.
Street
City
State
Zip Code
Phone (Include Area Code)
Home:
Business:
2.
SOCIAL SECURITY NUMBER
3.
Are you under 18 or over 70 years of age?
Yes
ÿ
ÿ
No
ÿ
ÿ
If yes, or if minimum and/or maximum age limits are established for the position
applied for, enter your date of birth here:
Mo.
Day
Year
4.
VETERANS CREDITS (See Instruction E)
If, for this examination, you wish to claim additional credit as an honorable
discharged veteran, complete the appropriate section on the last page of this
application.
5.
Are you a citizen of the United States?
s
s
Yes
s
s
No
If you are not a citizen of the United States, do you have the legal right to accept
employment in the United States?
σ
Yes
σ
No (Noncitizens may be required
to produce I151 or I551 Alien Registration Cards at time of appointment.)
6.
Have you been a legal resident of Wayne County for at
least four months up to and including the date of this
application?
YES NO
List the following jurisdictions you are currently a
resident
of:
School District
City or Village
Town
7.
Check appropriate box to the right of each question:
A. Were you ever dismissed or discharged from any
YES
NO
employment for reasons other than lack of work or
σ
σ
funds?
B. Did you ever resign from any employment rather
YES
NO
than face dismissal?
σ
σ
C. Did you ever receive a discharge from the Armed
YES
NO
Forces of the United States which was other than
σ
σ
“Honorable” or which was issued under other than
honorable circumstances?
D. Have you ever been convicted of any crime (felony
YES
NO
or misdemeanor)?
σ
σ
E. Have you ever forfeited bail bond posted to
YES
NO
guarantee your appearance in court to answer to
σ
σ
any criminal charge?
If you answered “YES” to any of the Questions 7 AE above, you may give
specifics under “Remarks” on page 4 of this application. If y ou elect not to
provide specifics, however, or if such explanation if insufficient, you may be
required to submit further information.
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.
8.
Have you any objections to this department making inquiry re
garding your character and qualifications from:
a) Your former employers?
σ
YES
σ
NO
b) Your present employer?
σ
YES
σ
NO
If answer is Yes to either question explain in “Remarks” section
on page 4.
Note: When filling out your application form, check to make sure that all
appropriate questions have been answered. A
n incomplete application may
result in its disapproval.
ALL STATEMENTS ARE SUBJECT TO VERIFICATION
I affirm that the statements made on this application (including any attached
papers) are true under the penalties of perjury.
Signature of Ap plicant
Date
Section 504 of the Rehabilitation Act of 1973 and the New
York State Human Rights Law prohibits discrimination in
employment because of age, race, creed, color, 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, creed, color,
national origin, sex, disability, marital status, or criminal
record in connection with employment.
THIS AFFIRMATION MUST BE COMPLETED
9.
EDUCATION
(If more space is required for full explanation, attach additional sheets or explain in “Remarks” section on page 3.
Type of Name of School
School Street Address
City, State, Zip
No. of
Years
Com
pleted
Were
you
Gradu
ated?
Day
or
Night
Full
or Part
Time
Type of
Course
or
Major Subject
Circle highest school year com
pleted in Grammer, Junior High,
or High School
1 2 3 4 5 6 7 8 9 10 11 12
High School
Number of
College
Credits
Received
Degree
Received
Date of
Degree
College,
University,
Professional or
Technical School
Other Schools or
Special Courses
If you have a high school equivalency diploma, indicate: Issuing government authority
Number
Date of Issue
10. If a college transcript is required and is not submitted
11. Do you have a valid N.Y.S. motor vehicle operator’s license?
herewith, will you please have transcript(s) forwarded?
YES
NO
YES
NO
If yes, class
number
date of expiration
12.
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 questions: If not currently licensed check this box
θ
Name of Trade or Profession
License Number
Granted by (licensing agency)
City or State of
Specialty
Date License First Issued
Registered From: (Mo./Yr.)
To: (Mo./Yr.)
13.
DESCRIPTION OF EXPERIENCE
Beginning with the most recent, describe below in detail ALL employment. If the examination announcement states that volunteer or unpaid experience is acceptable as qualifying,
describe it in the same way as paid work, showing its volunteer nature in the “Earnings” box. You are responsible for submitting an accurate, adequate and clear description of
your experience. Omissions or vagueness will NOT be interpreted in your favor. If you have had military service which includes experience pertinent to the position(s), describe
such experience as a separate employment. If your title or duties changed materially in the course of your service in any one organization, indicate such change clearly and as a
separate employment. (If more space is needed, attach 8½” x 11” sheets of paper.) Under “Duties” for each employment describe the nature of the work personally performed by
you, with estimated percentage of time spent on each type of work. State size and kind or working force, if any, supervised by you and the extent of such supervision.
LENGTH OF EMPLOYMENT
Mo. Yr Mo Yr
From / To /
Firm Name
Address
City and State
DESCRIBE DUTIES BELOW
EARNINGS (Circle One)
$ /Wk/Mo/Yr
TYPE OF BUSINESS
YOUR EXACT TITLE
SUPERVISOR’S NAME & TITLE
REASON FOR LEAVING
No. of hours worked per week
(exclusive of overtime)
LENGTH OF EMPLOYMENT
Mo. Yr Mo Yr
From / To /
Firm Name
Address
City and State
DESCRIBE DUTIES BELOW
EARNINGS (Circle One)
$ /Wk/Mo/Yr
TYPE OF BUSINESS
YOUR EXACT TITLE
SUPERVISOR’S NAME & TITLE
REASON FOR LEAVING
No. of
hours worked per week
(exclusive of overtime)
LENGTH OF EMPLOYMENT
Firm Name
Address
City and State
Mo. Yr Mo Yr
From / To /
DESCRIBE DUTIES BELOW
EARNINGS (Circle One)
$ /Wk/Mo/Yr
TYPE OF BUSINESS
YOUR EXACT TITLE
SUPERVISOR’S NAME & TITLE
REASON FOR LEAVING
No. of hours worked per week
(exclusive of overtime)
LENGTH OF EMPLOYMENT
Mo. Yr Mo Yr
From / To /
Firm Name
Address
City and State
DESCRIBE DUTIES BELOW
EARNINGS (Circle One)
$ /Wk/Mo/Yr
TYPE OF BUSINESS
YOUR EXACT TITLE
SUPERVISOR’S NAME & TITLE
REASON FOR LEAVING
No. of hours worked per week
(exclusive of overtime)
LENGTH OF EMPLOYMENT
Mo. Yr Mo Yr
From / To /
Firm Name
Address
City and State
DESCRIBE DUTIES BELOW
EARNINGS (Circle One)
$ /Wk/Mo/Yr
TYPE OF BUSINESS
YOUR EXACT TITLE
SUPERVISOR’S NAME & TITLE
REASON FOR LEAVING
No. of hours worked per week
(exclusive of overtime)
LENGTH OF EMPLOYMENT
Mo. Yr Mo Yr
From / To /
Firm Name
Address
City and State
DESCRIBE DUTIES BELOW
EARNINGS (Circle One)
$ /Wk/Mo/Yr
TYPE OF BUSINESS
YOUR EXACT TITLE
SUPERVISOR’S NAME & TITLE
REASON FOR LEAVING
No. of hours worked per week
(exclusive of overtime)
REMARKS REGARDING EXPERIENCE OR EDUCATION:
ALL STATEMENTS ARE SUBJECT TO VERIFICATION
3
INSTRUCTIONS AND INFORMATION
A.
ANNOUNCEMENT OF EXAMINATION
Before filling out your application, read carefully the announcement
for this examination.
When completing your application be sure to enter, at the top of
page 1, the examination number which identifies the examination
for which you are filing.
B.
ADMISSION TO EXAMINATION
Do not interpret a notice to appear for, or actual participation in the
examination, to mean that you have been found to meet fully the
announced requirements.
Depending on the time available before an examination, applicants
may be admitted to the examination on the basis of statements
made on the application or conditionally, without prior review of the
application. Such statements may not be reviewed and/or verified
until after the examination is held. At that time those candidates
not meeting the requirements will be disqualified and notified of
such disqualification. Those candidates who are subsequently
disqualified after taking the test will NOT be notified of their score.
Call or wire this agency immediately if you do not receive a notice
within three days of the date of examination informing you whether
or not you are to be admitted to the examination.
C.
CHANGE OF ADDRESS
Notify this agency immediately of any change of address. When
writing give the number and title of examination.
D.
SPECIAL ARRANGEMENTS
If you need special arrangements because you are a Religious
Observe
r (for religious reasons cannot be tested on date of
examination(s), or a Handicapped Person (require special
arrangements in order to participate in the examination(s), you
must notify the agency no later than the last date of filing for the
examination. Your request must include the examination number
and title and the type of special arrangements required.
Check one:
Religious Observer
Handicapped Person
E.
VETERANS CREDITS
If you are making a claim for veterans credits with this application,
be sure you read the following information very carefully:
Check the appropriate box below and answer questions A – F.
Failure to do so, accurately and completely, may result in a denial
of your claim.
Disabled War Veteran
NonDisabled War Veteran
A.
Have you ever served in the Armed Forces of the
YES NO
United States? (The “Armed Forces of the United
States” means the Army, Navy, Marine Corps, Air
Force and Coast Guard, including all components
thereof and the National Guard when in the service
of the United States pursuant to call as provided by
Law on a fulltime basis other than active duty for
training purposes.)
B.
If “YES” did you receive a discharge which was
YES NO
honorable or were you released under honorable
circumstances?
C.
Did you serve in the Armed Forces of the United
YES NO
States during any of the following periods?
–
World War I…April 6, 1917November 11, 1918
–
World War II…December 7, 1941December 31, 1946
–
Korean Conflict…June 27, 1950January 31, 1955
–
Vietnam Conflict…December 22, 1961May 7, 1975
–
Persian Gulf Conflict…August 2, 1990the date upon
which such hostilities end
OR
Commissioned corps of the US public health services;
YES NO
July 29,1945September 1, 1945 and June 26, 1950
July 3, 1962.
OR
The armed forces expeditionary medal, navy expeditionary
YES NO
medal, or marine corps expeditionary medal for:
–
Hostilities in Lebanon…June 1, 1983December 1, 1987
–
Hostilities in Grenada… October 23, 1983November 21,
1983
–
Hostilities in Panama…December 20, 1989January 31,
1990
D.
Are you currently a resident of New York State?
YES NO
E.
Since January 1, 1951, have you used additional
YES NO
credits as a disabled or nondisabled veteran for
appointment to any position in he public
employment of New York State or any of its civil
divisions?
If you are claiming credits as a disabled war veteran, you must in
addition to meeting the requirements as indicated by a “YES” answer to
questions 10AD and a “NO” answer to question 10E, be certified by the
veteran’s administration as being entitled to receive payments for a
serviceconnected disability rated at ten (10) percent or more, incurred
during a “Time of War” as indicated in question C.
Persons claiming credits as disabled war veterans will be contacted by
this agency for additional information as necessary.
All claims and grants of veterans credits are tentative and must be
verified through inspection of discharge papers and other related
documents, as necessary, prior to the establishment of the eligible list.
You will be advised as to which documents must be produced by you
for this verification. All statements you make in support of your claim for
additional credits are subject to investigation and substantiation by this
agency. In the event of subsequent disclosure of any material
misstatement or fraud in this claim, your appointment may be rescinded
and you may be disqualified from further appointment on which you
have been granted additional credits as a result of such material
misstatement or fraud.
ALL STATEMENTS ARE SUBJECT TO VERIFICATION
REMARKS:
Section 50b of the New York State Civil Service Law
requires that all applicants for examination be asked the
following questions:
1.
Have you any loans made or guaranteed by the New
York State Higher Education Services Corporation
which are currently outstanding?
………………..Yes
……………….No
If yes, are you presently in default?
………………..Yes
………………No
4
Please submit a copy of your DD214 verifying the character of
your discharge and dates of service.
Branch of Service
FROM:
TO:
Dates of Military Service
WAYNE COUNTY SHERIFF’S DEPARTMENT
Criminal Record Check Waiver Only
I, __________________________, having been born on ___/___/___, do hereby grant
permission to the Wayne County Sheriff’s Department to inquire into my financial and/or
personal background to determine if I have ever been arrested for, or convicted of a
crime. This information is for the purpose of a job application, and I hereby agree that
this information can be released to the Williamson Central School District, PO Box 900,
Williamson, NY 14589.
______________________ _________________________________________
Date Signature
______________________ _________________________________________
Date Signature of Witness, Title
PRINT ALL INFORMATION REQUESTED BELOW
In order to obtain the requested information, please complete the following:
Last Name ______________________ First Name _______________ M.I. ____
Maiden Name and/or Aliases _________________________________________
Social Security # ____________ Place of Birth __________________________
Nationality ______________________
FOR DEPARTMENT USE ONLY
A RECORD CHECK WAS CONDUCTED FROM THE INFORMATION SUPPLIED
ABOVE AND THE FOLLOWING WAS DETERMINED:
_____________________________________________________________________
DATE __________________ OFFICER’S SIGNATURE _______________________
NAME
DATE
PLEASE COMPLETE AND ATTACH TO YOUR APPLICATION
POSITION APPLYING FOR
Are you interested in substitute employment?
Yes
No
If you are interested in substitute employment, please indicate your choices:
Clerical
Teacher Aide
Food Service Helper
Cleaner (Evenings only)
Monitor: Bus
Study Hall
Playground/Classroom
Bus Driver
I wish to substitute in:
Business/District Office
Elementary School
Middle School
High School
Bus Garage
References:
Please list three individuals who are familiar with your personal qualities and job performance.
NAME
Business/
Organization
Phone
Number
Relationship
(Supervisor/
CoWorker)
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