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FORM NYS-APP(9/12 L) www.cs.ny.gov

APPLICATION FOR NYS EXAMINATIONS

Send

Application Processing

Completed

New York State Department of Civil Service

Application to:

Albany, NY 12239

 

 

Read Instructions on Page 4 First - Please Print Clearly

 

Mo.

Day Yr.

You must file a separate

Announced

 

 

application for each

Test Date:

 

 

different test date.

 

 

 

 

 

 

 

 

Exam No(s).

Titles(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

First Name

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MailingAddress: No., Street,Apt., or P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City or Post Office

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

 

Day Phone

 

 

 

 

 

 

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

RELIGIOUSACCOMMODATION

I cannot be tested on the scheduled test date due to a conflict with a religious observance or practice. (See Page 4.)

REASONABLEACCOMMODATIONS IN TESTING

I require reasonable accommodations to take this test. (See Page 4.)

ELIGIBILITYFOR EMPLOYMENT

YoumustbelegallyeligibletoworkintheUnitedStatesattimeofappointment and throughout your employment with New York State. If appointed, you must produce documents that establish your identify and eligibility to work in the United States, as required by the Federal Immigration Reform and ControlAct of 1986, and the Immigration and NationalityAct.

For Civil Service Use Only

W G U

STUDENT LOANS

Yes

 

No

Have you any loans made or guaranteed by the NYS Higher Education Services Corporation which are currently

 

 

 

 

outstanding?

Yes

 

No

If so, are you currently in default on any such loan?

ADDITIONALQUESTIONS FOR OPEN-COMPETITIVEAPPLICANTS ONLY:

Yes

 

No

Were you ever discharged from any employment except for lack of work for funds, disability or medical condition?

Yes

 

No

Did you ever resign from any employment rather than face discharge?

Yes

 

No

Did you ever receive a discharge from theArmed Forces of the United States which was other than “Honorable” or

 

 

 

which was issued under other than honorable conditions?

Yes

 

No

Have you ever been convicted of any crime (felony or misdemeanor)?

Yes

 

No

Are you now under charges for any crime?

If you answered YES to any of these questions, provide details under REMARKS on Page 3. Your failure to answer any of these questions

or to provide details will significantly delay any determination concerning your qualifications and may deprive you of potential employment opportunities.

NON-REFUNDABLE PROCESSING FEE

Please read exam announcement and information on Page 4.

Check One

No Fee Is Due Because:

I have enclosed the fee.

I am a NY State employee and my fee is paid by my union

(Enclose a check or money order payable to the

for an open-competitive examination.

NYS Department of Civil Service).

(CSEANegotiating Units 02, 03, 04 or 47)

DO NOT SEND CASH.

I am unemployed and primarily responsible for the support

(The Fee will NOT BE REFUNDED

of a household.

if your application is DISAPPROVED.)

I am receiving public assistance as described on Page 4.

 

I affirm under penalties of perjury that all statements made on this application (including any attached papers) are true. I understand that all statements made by me in connection with this application are subject to investigation and verification and that a material misstatement or fraud may disqualify me from appointment and/or lead to revocation of my appointment.

X Signature ofApplicant Date Please print any other last name by which you are or have been known.

DO NOT COMPLETE THIS SECTION UNLESS YOU:

1.Wish to claim War Time Veterans Credits,AND

2.Have NOT used veterans credits for appointment to a position in NY State or Local Government.

EXTRACREDITS FOR WAR TIME VETERANS

YOURANSWERS MUST BE ‘YES’TO BE ELIGIBLE FORADDITIONALCREDITS.

Yes

 

No

I expect to receive or have already received, a discharge which was honorable or release under honorable circumstances from theArmed

 

 

 

 

Forces of the United States. The “Armed Forces of the United States” means theArmy, 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

Yes

 

No

a full-time active duty basis other than active duty for training purposes.

 

 

I am now serving, or have served, on an active duty basis other than active duty for training purposes during one or more of

 

 

 

 

the following Time of War periods.

 

 

 

 

 

In theArmed Forces:

or earned theArmed Forces, Navy, or Marine

or in the U.S. Public Health Service

 

 

 

• Aug. 2, 1990 to the date when

Corps expeditionary medal for service in:

• June 26, 1950 to July 3, 1952;

 

 

 

the Persian Gulf hostilities ends:

• (Panama) Dec. 20, 1989 to Jan. 31, 1990;

• July 29, 1954 to Sept. 2, 1945.

 

 

 

• Feb. 28, 1961 to May 7, 1975;

• (Lebanon) June 1, 1983 to Dec. 1, 1987;

 

 

 

 

• June 27, 1950 to Jan. 31, 1955;

• (Grenada) Oct. 23, 1983 to Nov. 21, 1983;

 

Yes

 

No

• Dec. 7, 1941 to Dec. 31, 1946;

 

 

 

I am a United States citizen or an alien lawfully admitted for permanent residence.

 

 

 

To claim additional credits as a Disabled Veteran, you must also answerYES to this question:

Yes

No

I have a service connected disability rated at 10% or more by the US Department of VeteransAffairs. This disability was incurred during

 

 

a “Time of War” period listed above.

New York State Residency Requirement for Extra Credits as a War Time Veteran or Disabled Veteran: You will be required to provide proof of current

New York residency at time of appointment.

It is the policy of the State of NewYork to provide forand promote equal opportunity employment, compensation, and otherterms and conditions of employment without discrimination on the basis of age, race, color, religion, disability, national origin, gender, sexual orientation, veteran ormilitary service memberstatus, marital status, domestic violence victim status, genetic predisposition or carrier status, or arrest and/or criminal conviction record unless based upon a bona fide occupational qualification or other exception.

It is the policy of New York State Department of Civil Service to provide qualified persons with disabilities equal opportunity to participate in and receive the benefits, services, programs and activities of the Department, and to provide such persons reasonable accommodations and reasonable modifications as are necessary to provide such equal opportunity, including accommodations in the examination process. Further, it is the policy of the Department to provide reasonable accommodations for religious observers.

FORM NYS-APP (9/12 L)

 

www.cs.ny.gov

 

Application for NYS Examinations

Page 2

YOUR EDUCATION:

Read the exam announcement for educational requirements, if any. If specialized coursework is required, attach a copy of the transcript or a list of the required courses and the number of credit hours you completed.

Do you have a High School or

Yes

If yes, Name and location of High School

 

 

 

 

 

 

Equivalency Diploma?

No

or Issuing Governmental Authority:

 

 

 

 

 

 

 

College, University, Professional or

 

Semester

Quarter

 

Type of

Major Subject

Did You

Degree

 

 

Credits

Hours

 

Degree

or Type of

 

Technical Schools

 

 

 

Graduate

Expected

 

 

 

Received

Received

 

Received

Course

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

Yes

MO.

YR.

 

 

 

 

 

 

 

 

 

 

No

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (City, State)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

Yes

MO.

YR.

 

 

 

 

 

 

 

 

 

 

No

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (City, State)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LICENSE OR CERTIFICATION:

 

 

 

 

 

 

 

 

 

 

 

Complete the following if a license, certificate or other authorization to practice a trade or profession is required on the announcement(s).

Trade or Profession

License Number

Date License

Registration

 

 

If you are not

 

 

First Issued

MO.

YR.

MO.

YR.

currently licensed,

 

 

 

FROM

/

TO

/

check this box:

Specialty

Granted by (licensing agency)

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE YOUR EXPERIENCE:

Beginning with your most recent, list all employment, military service, or volunteer experience that shows you meet the minimum qualifications for the examination(s). We cannot interpret omissions or vagueness in your favor. You are responsible for an accurate and clear description of your experience. Do not send your resume. Under DUTIES describe the nature of the work which you personally performed including the estimated percentage of time spent on each type of activity. If you supervised, state how many people and the nature of such supervision.

LENGTH OF EMPLOYMENT

FIRM NAME

ADDRESS

CITY AND STATE

MO.

YR.

MO.

YR.

 

 

 

FROM

/

TO

/

 

 

 

EARNINGS

 

(CIRCLE ONE)

DUTIES:

 

 

$

 

/WK./MO./YR.

 

 

 

 

 

 

TYPE OF BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR EXACT TITLE

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF YOUR SUPERVISOR

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR’S TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of hours worked per week

 

 

 

 

(exclusive of overtime):

 

 

 

 

 

 

 

 

LENGTH OF EMPLOYMENT

FIRM NAME

ADDRESS

CITY AND STATE

MO.

YR.

MO.

YR.

 

 

 

FROM

/

TO

/

 

 

 

EARNINGS

 

(CIRCLE ONE)

DUTIES:

 

 

$

 

/WK./MO./YR.

 

 

 

 

 

 

TYPE OF BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR EXACT TITLE

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF YOUR SUPERVISOR

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR’S TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of hours worked per week

 

 

 

 

(exclusive of overtime):

 

 

 

 

BE SURE TO READ THE REQUIRED QUALIFICATIONS ON THE EXAMINATION ANNOUNCEMENT(S)

ALL STATEMENTS ARE SUBJECT TO VERIFICATION

FORM NYS-APP (9/12 L)

 

 

 

 

www.cs.ny.gov

 

 

 

 

 

 

 

 

 

 

Application for NYS Examinations

Page 3

 

 

 

 

LENGTH OF EMPLOYMENT

FIRM NAME

ADDRESS

CITY AND STATE

MO.

YR.

MO.

YR.

 

 

 

FROM

/

TO

/

 

 

 

EARNINGS

 

(CIRCLE ONE)

DUTIES:

 

 

$

 

/WK./MO./YR.

 

 

 

 

 

 

TYPE OF BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR EXACT TITLE

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF YOUR SUPERVISOR

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR’S TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of hours worked per week

 

 

 

 

(exclusive of overtime):

 

 

 

 

 

 

 

 

LENGTH OF EMPLOYMENT

FIRM NAME

ADDRESS

CITY AND STATE

MO.

YR.

MO.

YR.

 

 

 

FROM

/

TO

/

 

 

 

EARNINGS

 

(CIRCLE ONE)

DUTIES:

 

 

$

 

/WK./MO./YR.

 

 

 

 

 

 

TYPE OF BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR EXACT TITLE

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF YOUR SUPERVISOR

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR’S TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of hours worked per week

 

 

 

 

(exclusive of overtime):

 

 

 

 

 

 

 

 

LENGTH OF EMPLOYMENT

FIRM NAME

ADDRESS

CITY AND STATE

MO.

YR.

MO.

YR.

 

 

 

FROM

/

TO

/

 

 

 

EARNINGS

 

(CIRCLE ONE)

DUTIES:

 

 

$

 

/WK./MO./YR.

 

 

 

 

 

 

TYPE OF BUSINESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YOUR EXACT TITLE

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF YOUR SUPERVISOR

 

 

 

 

 

 

 

 

 

 

 

SUPERVISOR’S TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of hours worked per week

 

 

 

 

(exclusive of overtime):

 

 

 

 

REMARKS:

(Attach additional 8 ½” x 11” sheets if necessary.)

FORM NYS-APP (9/12 L)

www.cs.ny.gov

Application for NYS Examinations

Page 4

EXAMINATION APPLICATION

Use this form to apply for all New York State Civil Service examinations (the five-digit examination number). Read each exam announcement carefully to be sure that you meet the Minimum Qualifications.

You must file a separate application for each different test date. You may list up to five exam numbers on one application, as long as they are all being held on the same date.

Unless the exam announcement has different instructions, mail your application (and the required processing fee, if any) to Application Processing, NYS Department of Civil Service, Albany, NY 12239.

ADMISSION TO EXAMINATION

We usually review your application before the test to be sure that you qualify. Generally we will advise you if we need more information. You may be admitted to the test pending a full review of your application. If you take the test but your application is disapproved later, you will not receive a test score. If your application is disapproved, we will notify you of the reason.

If you are applying for a written test and you do not receive an admission notice from us at least three days prior to the test date, immediately call (518) 474-6470 in the Albany area, or toll free at 1-877-697-5627 (press 2, then press 1).

PLACE OF EXAMINATION

Unless the exam announcement states otherwise, written tests are

Albany

Kingston

Rochester

held in the following locations, although some may not be open for

Amsterdam

Middletown

Saranac Lake

every examination. You will be assigned to the nearest OPEN

Binghamton

New York City (Manhattan) Syracuse

location based on the postal ZIP code for your mailing address.

Buffalo

Nyack

Utica

 

Fredonia

Port Jefferson

Watertown

Oral tests are usually held in Albany only.

Hicksville

Poughkeepsie

 

RELIGIOUS ACCOMMODATIONS

Most written tests are held on Saturdays. If you cannot take the test on the announced test date due to a conflict with a religious observance or practice, check the box under “Religious Accommodation.” We will make arrangements for you to take the test on a different date (usually the following day).

REASONABLE ACCOMMODATIONS IN TESTING

We provide reasonable accommodations for persons with disabilities to take a test. If you need a reasonable accommodation, check the box, "I require reasonable accommodations to take this test." On or before the last date for filing applications, write to the Department of Civil Service or call (518) 457-2487 (press 2, then press 2) (in the Albany area) or 1-877-697-5627 (outside of the Albany area) and describe the accommodation you need. For TDD services, call NY Relay at 711 (requires a fee) or 1-800-662-1220.

NON-REFUNDABLE PROCESSING FEE

Refer to the front of the exam announcement for the required processing fee. Enclose a check or money order for the total amount required, made payable to the New York State Department of Civil Service. DO NOT SEND CASH. If your application is disapproved, the fee will not be refunded. Check the box, “I have enclosed the fee.”

If you are a NYS employee in a position represented by CSEA and you are applying for an OPEN-COMPETITIVE examination, you are not required to submit a processing fee under current negotiated agreements. Check the box “I am a NYS employee and my fee is paid by my union for an open-competitive examination (CSEA Negotiating Units 02, 03, 04 or 47).” Refunds will not be issued to employees covered by the agreements if they submit a fee.

No fee is due if you are unemployed and primarily responsible for the support of a household. Do not enclose any payment with your application.

Check the box, “I am unemployed and primarily responsible for the support of a household.”

No fee is due if you are determined eligible for Medicaid, or receiving Supplemental Social Security payments, or Public Assistance (Temporary Assistance for Needy Families/Family Assistance or Safety Net Assistance) or are certified Job Training Partnership Act/Workforce Investment Act eligible through a state or local social service agency. Do not enclose any payment with your application. Check the box, “I am receiving public assistance.”

All claims are subject to verification. Those not supported by appropriate documentation are grounds for barring or rescinding an appointment.

EXTRA CREDITS FOR WAR TIME VETERANS

Answering these questions means that you are requesting the extra credits. Do not answer the questions if you are not a war time active duty member of the Armed Forces or a War Time Veteran or if you do not want to request the extra credits. If you are currently in the Armed Forces on full-time active duty (other than for training) or if you are a War Time Veteran or Disabled Veteran, you are eligible for extra credits added to your exam score if you pass. These extra credits can be used only once for any permanent government employment in New York State. If you want to have these extra credits added to your exam score, you must answer the questions now. You can waive the extra credits later if you wish. At the time of interview and appointment you will be required to produce the documentation, such as discharge papers, to prove that you are eligible for the extra credits.

ADDITIONAL EXAMINATION CREDITS PURSUANT TO CIVIL SERVICE LAW SECTION 85-a

If you are a child of a police officer or firefighter who was killed in the line of duty in the service of New York State, you may be entitled for additional examination credits pursuant to Civil Service Law Section 85-a. For further information, please contact the Department of Civil Service at (518) 473-8102.

PERSONAL PRIVACY PROTECTION LAW NOTIFICATION

The information which you are providing on this application is being requested pursuant to Section 50.3 of the New York State Civil Service Law for the principal purpose of determining the eligibility of applicants to participate in the examination(s) for which they have applied. This information will be used in accordance with Section 96(1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e), and (f). Failure to provide this information may result in disapproval of the application. This information will be maintained by the Director, Division of Staffing Services, Department of Civil Service, Albany, New York 12239. For further information, relating only to the Personal Privacy Protection Law, call (518) 457-9375. (For examination information, call (518) 457-2487 (press 2, then press 3); or toll free at 1-877-697-5627 (press 2, then press 3).