1 | P a g e ALL STATEMENTS ARE SUBJECT TO VERIFICATION
APPLICATION FOR EXAMINATION OR EMPLOYMENT
FOR COUNTY OFFICES, TOWNS, VILLAGES, SCHOOL DISTRICTS,
LIBRARIES AND SPECIAL DISTRICTS
1.
Date Received _____________ Approved ______________
Conditional _____________ Disapproved ______________
CIVIL SERVICE DEPT.
USE ONLY
2. NAME AND LEGAL RESIDENCE
_______________________________________________________________
Last Name First Name Middle Initial
____________________________ __________________________________
Street Address or Road
Home Phone Number
______________
Cell Phone:___________________
Email Address:
__________________________________________________
If mailing address is different:
____________________________
__________________________________
Street Address or Road
______________________________________________________________
City, Town, Village State Zip County
Social Security Number
- -
4. A. Are you currently a U.S. Citizen? YES
NO
B. If not, do you have the legal right to accept
Employment in the United States?
Please give alien registration number:
YES
NO
_____________________________________
C. Are you a retiree from New York State or any
civil division thereof?
YES
NO
417 Liberty Street, Suite 1007, Penn Yan, NY 14527
315-536-5112
YATES COUNTY
PERSONNEL DEPARTMENT
Yates County is an Equal Opportunity Employer. The County does not discriminate on the basis of sex, (including gender identity or
expression and the status of being transgender), sexual orientation, race, color, national origin, religion, disability, pregnancy, age, marital
status, veteran status, military status, genetic information or predisposing characteristics, domestic violence victim status, or any other
protected status. Discrimination based on membership in these categories is prohibited by federal, state, or (where applicable) local laws.
Name
Years
Months
County of:
Residency Requirements: Candidates must meet the Residency
Requirements as stated on the examination announcement. You must
complete the following to determine if you meet these residency
requirements.
7. Indicate how long this has been your legal residence, up to the date of
this application, showing that you meet the residency requirements as
announced.
State of:
3. Police Officer & Firefighter Candidates Only: Month Day Year
Date of Birth
6. If you have filed or are filing SEPARATE applications for Civil Service
Examinations being held on the same date, attach the CROSSFILER
APPLICATION. Call to make arrangements no later than two weeks
before the test date.
Religious Observer Military Disability
5. Special Testing Arrangements (Refer to General Conditions and
Instructions). If you need Special Testing Accommodations to take the
examination, contact the Civil Service Office at (315) 536-5112.
POSITION TITLE
EXAM NUMBER
____________________________
____________________________
_
___________________________________________________________
City, Town, Village State Zip County
This application is part of your examination. Answer all
questions fully. A resume, if submitted, cannot substitute
for the application. You are encouraged to read the General
Conditions and Instructions for more information.
2 | P a g e ALL STATEMENTS ARE SUBJECT TO VERIFICATION
8. Veterans Credits:
If you wish to apply for Veterans Credits, complete the following questions and complete the Application for
Veterans Credits (Refer to General Conditions and Instructions).
Yes
No
Have you ever served in the Armed Forces of the United States?
(The Armed Forces 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 US pursuant to call as provided by Law on a full-time active duty basis other than
active duty for training purposes).
Have you ever used additional credits as a disabled or non-disabled veteran for appointment to any position in the public
employment of New York State or any of its civil divisions?
Do you have a service connected disability rated at 10% or more by the U.S. Department of Veterans Affairs?
After you were permanently appointed using non-disabled veteran credits, were you subsequently certified as having a service
connected disability rated at 10% or more by the U.S. Department of Veterans Affairs?
Are you currently a resident of New York State?
9. Additional Questions: Check the appropriate box to the right of each question.
Were you dismissed or discharged from any employment for reasons other than lack of work or funds?
Did you ever resign from any employment rather than face dismissal?
Did you ever receive a discharge from the Armed Forces of the United States which was other than “Honorable” or which was
issued under the “Other than Honorable” circumstances?
Have you ever been convicted of any crime (felony or misdemeanor)?
Are you now under charges for any crime?
Are you an Exempt Volunteer Fireman?
If you answered yes to any of the above questions, you may give specifics below. If you elect not to provide specifics, or if such explanation is 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 position(s) for which you are applying.
REMARKS:____________________________________________
_______________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
10. Licenses: If a license, certificate, or authorization to practice a trade or profession is listed as a requirement for the title for which
you are applying, please complete the section below and submit the appropriate record (i.e. license, certificate, permit, etc.) that
verifies you satisfy this requirement.
Name of Trade or Profession: Specialty:
License Number:
Granted by (Licensing Agency): City/State
Date License First Issued: Registered From: Registered
To:
Yes
No
3 | P a g e ALL STATEMENTS ARE SUBJECT TO VERIFICATION
11. 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. If required to indicate specific course work, do
so on an attached sheet.
If education and/or training is listed as a requirement for the title for which you are applying, please complete the section below and
submit the appropriate record (i.e. diploma, transcript, record of training completion and date completed, etc) that verifies you satisfy
this requirement. If the requirement is education, you should provide the record for your highest level of education obtained.
High School Yes No
Have you ever graduated from High School or do you have possession of a High School Equivalency Diploma?
If Yes, Name and Location of High School or Issuing Government
Authority:
Equivalency Diploma Number:
College, University, Professional or Technical School
Name of School
Number
of College
Credits
Degree Earned
Major Subject/Courses
Did You
Graduate?
Date Degree
Expected or
Received
Yes
No
Length of Employment
Firm Name:
From:
To:
Firm Address:
Description of Duties:
Your Exact Title
Name of Your Supervisor
Supervisor’s Title
Hours worked / wk.
(exclusive of overtime)
Reason for Leaving
Length of Employment
Firm Name:
From:
To:
Firm Address:
Description of Duties:
Your Exact Title
Name of Your Supervisor
Supervisor’s Title
Hours worked / wk.
(exclusive of overtime)
Reason for Leaving
12. Experience: All sections must be filled out completely even if you attach a resume. Begin with the most recent employment. List all
employment or military service that shows that you meet the minimum qualifications for the examination. Omissions or vagueness will not be interpreted
in your favor. Under Description of Duties, clearly describe the nature of work which you personally performed. Part-time experience will be prorated
unless otherwise stated on the examination announcement. Verified and documented volunteer experience will only be credited when specifically stated
on the examination announcement. If you move to a different position within the same organization, indicate so in a separate employment
box. You may attach additional sheets if you need more space.
Attended
ToFrom
Years
Credited
State
Other Schools
or
Special Courses
Length of Employment
Firm Name:
From: To:
Firm Address:
Description of Duties:
Your Exact Title
Name of Your Supervisor
Supervisor’s Title
Hours worked / wk.
(exclusive of overti
me)
Reason for Leaving
Length of Employment
Firm Name:
From: To:
Firm Address:
Description of Duties:
Your Exact Title
Name of Your Supervisor
Supervisor’s Title
Hours worked / wk.
(exclusive of overti
me)
Reason for Leaving
THIS AFFIRMATION MUST BE COMPLETED
I affirm, subject to the penalties of perjury, that the statements made in this application, including statements made in any
accompanying 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. I give the employer the right to inve
stigate all referenc
es and to secure
additional job related information about me. I hereby release from liability the employer and its representatives for seeking
such information and all other persons, corporations or organizations for furnishing such information. If the position I am
applying for is covered by the employer’s drug testing policy, I understand that as a condition of appointment to this
position, I will be required to take and successfully pass a pre-emp
loyment drug test.
_______________________________ _______________________________ _______________
Signature of Applicant Print Name Date
4 | P a g e ALL STATEMENTS ARE SUBJECT TO VERIFICATION
5 | P a g e ALL STATEMENTS ARE SUBJECT TO VERIFICATION
Application Forms. Applications may be obtained at the Yates County Civil Service
Office or on the website at www.yatescounty.org. Candidates will be notified of the time
and place of the examination.
Application Deadline. Applications received after the deadline of the last filing date will
not be considered eligible for this examination.
Change of Address. You must notify the Civil Service Office of any change of address,
telephone number or email address.
Special Rights for Military Personnel.
Application Filing Period Extension. Individuals serving on active duty in the Armed
Forces during the filing period for a civil service examination, or individuals who have been
discharged with other than a dishonorable discharge after the filing period has commenced
will be permitted to file an application for examination no later than two business days
prior to the scheduled examination date, or the last date to file, whichever is later.
Make Up Examination. Any member of the Armed Forces who properly filed, within the
announced filing period, an application for a competitive examination but was unable to
participate in the examination due to active military service, will be provided with a
special make-up examination under the terms and conditions deemed appropriate by the
New York State Department of Civil Service and/or the Yates County Civil Service Office.
Examination Fee. A fee of $17.00 is required for each separately-numbered examination
for which you apply. A $27 fee is required when applying for the Police Officer/Deputy
Sheriff Examination. If applying for both Police and Deputy Sheriff examinations, a $27
fee is due for each application. The required fee must accompany your application. If you
wish to pay by credit card, please use our online application or send check or money
order payable to Yates County. As no refund will be made, you are urged to compare your
qualifications carefully with the requirements for admission and file only for those
examinations for which you are clearly qualified.
Examination Fee Waiver. The examination fee will be waived for (1) those applicants
who are unemployed and primarily responsible for the support of a household; (2) those
applicants who are receiving SSI or public assistance (Family Assistance or Safety Net
Assistance); (3) those applicants certified as Workforce Innovation and Opportunity Act
(WIOA). If you wish to apply for a fee waiver, you must complete the Fee Waiver Form
and attach it to your application. This form can be obtained at the Civil Service Office or
on the website at www.yatescounty.org.
Notice to Appear for Examination. Accepted candidates will be notified when and where
to appear for the examination. If an application is disapproved, due notice will be sent.
Use of Calculators. Unless otherwise notified, candidates are permitted to use quiet,
hand-held, solar or battery powered calculators. Devices with typewriter keyboards, spell
checkers, personal digital assistants, address books, language translators, dictionaries, or
any similar devices are prohibited. You may not bring books or other reference material to
the test site.
Failure to Appear for Exam. Candidates who fail to appear for the exam as scheduled
will be eliminated from further consideration for this competitive examination.
Examination Preparation and Rating. This written examination is being prepared and
rated by the New York State Department of Civil Service in accordance with Section 23-2
of the Civil Service Law. The provisions of the New York State Civil Service Rules and
Regulations dealing with the rating of examinations will apply to this written examination.
Eligible List. The minimum qualifications listed in this announcement have been
approved by the Yates County Civil Service Office for the purpose of evaluating a
candidate's education, training and experience to determine admission to this examina-
tion. This examination is being conducted to establish a Civil Service Eligible List which
will be certified to appointing authorities to fill available vacancies. Candidates whose
names are certified for appointment have only met the minimum qualifications to take the
examination. All candidates who pass the examination will be placed on an eligible list.
Unless otherwise specified, the final rank order of the eligible list will be determined on
the basis of the scores received on the written test, plus Veterans Credits and Seniority
Credits where appropriate. The eligible list established as a result of this examination will
remain in force for
at least one year and may expire when a new eligible list is
established.
Seniority Credits (Promotional Exams Only). Seniority Credits will be added to an
eligible score based on continuous permanent competitive class service in the jurisdiction
holding the examination. Service would be credited up to and including the date of
examination as follows:
Each additional 5 years will be credited 1 point in accordance with the above schedule.
Additional Credits for Eligible Children or Siblings of Firefighters and Police
Officers Killed in the Line of Duty. If you are either a child or sibling of a Firefighter
or Police Officer killed in the line of duty as defined in Civil Service Law Section 85-a (see
below), you may be entitled to receive an additional ten points in a competitive
examination for original appointment in the same municipality in which the deceased
firefighter or police officer had served. A candidate claiming such credit has a minimum of
two months from the application deadline to provide the necessary documentation to
verify additional credit eligibility. However, no credit may be added after the eligible list
has been established. You must contact this office regarding these credits upon
submission of your application for examination.
Civil Service Law Section 85-a. Children of firefighters and police officers killed in the
line of duty are eligible for these additional credits.
No. of Years Credits No. of Years Credits No. of Years Credits
Less than 1 year 0 6 to 10 years 2 16 to 20 years 4
1 to 5 years 1 11 to 15 years 3 21 to 25 years 5
Special Testing Arrangements. If you need accommodation to take the examination
for one of the reasons outlined below, please check the appropriate box on the
Examination Application and contact the Civil Service Office at (315) 536-5112.
Religious Accommodations. Most written exams are held on Saturdays. If you cannot
take the exam on the announced date due to a conflict with a religious observation or
practice, arrangements will be made so that you can take the examination on an alternate
date.
Reasonable Accommodation for Individuals With a Disability. A reasonable
accommodation will be made for individuals with a disability during the application and
examination process. You must provide documentation as to the accommodation you
need to apply for and/or take the examination.
Other Reasons. An alternate exam date may be requested for one of the following
reasons. Documentation supporting the request will be required.
1. A death in the immediate family or household within the week preceding
the exam date.
2. Medical emergencies involving the candidate or member(s) of the
candidate’s immediate family.
3. Military Orders (a copy of the orders is required).
4. Wedding – must be a member of the wedding party or an immediate family
member of the bride or groom.
5. Vacation for which a non-refundable down payment was made before the
exam announcement was issued.
1. Used Non-Disabled Veterans Credits to obtain a civil service appointment or
promotion with New York State or a local government; and
2. Subsequent to such appointment, are certified by the US Department of
Veterans Affairs as having a service connected disability rated at 10% or
more.
Application Verification and Background Checks – Statements made on the
Examination Application are subject to verification. A clearance from the
Commissioner of Education will be required for employment within a school district for
those positions that are designated by the school district as having direct contact with
students.
Veterans Credits. The following information and instructions pertain to those candidates
who are claiming Veterans Credits. Please note that Veterans Credits will not be granted
after the establishment of the eligible list.
• If you are claiming Veterans Credits as either a disabled or non-disabled veteran, you
must check the appropriate box on the Application for Examination form and answer all
questions accurately and completely. You must also complete the Application for Veterans
Credits obtained in the Yates County Civil Service Office or on the website at
www.yatescounty.org, and submit the DD-214 Discharge Papers showing that you have
an honorable discharge. Failure to do so may result in a denial of your claim for Veterans
Credits.
• If you are claiming credits as a disabled veteran, you must in addition to meeting the
requirements as indicated on the Examination Application, be certified by the United
States Department of Veterans Affairs as being disabled in the actual performance of duty
in any war; that the disability is rated at ten percent or more, and that the disability exists
at the time of application for appointment or promotion.
• All claims and grants for Veterans Credits are tentative and must be verified through
inspection of discharge papers and related documents prior to the establishment of the
eligible list. All statements you make in support of your claim for Veterans Credits are
subject to investigation and substantiation by the Yates County Civil Service Office. In the
event of subsequent disclosure of any material misstatement or fraud in your 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.
• Any candidate who is currently serving in the Armed Forces of the United States on a
full-time active duty basis, other than active duty for training, may file for Veterans Credits
on an examination prior to the list being established.
• Conditional Veterans Credits. A qualified candidate receiving Conditional Veterans
Credits will be restricted from certification using the credits until the appropriate
documentary proof indicating that the individual received an honorable discharge or was
released under honorable circumstances has been presented. It is the candidate's
have the restriction removed and be certified at a score including the Veterans Credits.
Until such documentation is submitted, a candidate may only be certified with the
examination score, not including the Veterans Credits.
• Additional Veterans Credits. Effective January 1, 2014, additional Veterans Credits
may be granted to veterans who:
