GENESEE COUNTY HUMAN RESOURCES

County Building I, 15 Main Street, Batavia, NY 14020 Phone: (585) 344-2550, Ext. 2223
GENESEE COUNTY	Web Site: www.co.genesee.ny.us

APPLICATION FOR EXAMINATION OR EMPLOYMENT

IMPORTANT INSTRUCTIONS: You must complete this entire application, even if you include a resume. If signing up for a civil service exam, you must read the exam announcement for additional instructions. Answer all questions thoroughly. All statements are subject to verification. Incomplete applications may be disapproved.

________________________ Position Title

________________
Exam Number	-OR-

____________________ Agency

NAME 	
LAST	FIRST	MIDDLE

HOME ____________________________________________________________________ ADDRESS	NUMBER	STREET	CITY	STATE	ZIP

MAILING __________________________________________________________________ ADDRESS(IF DIFFERENT FROM ABOVE) NUMBER	STREET	CITY	STATE	ZIP

HOME PHONE(_ _ _)_ _ _ - _ _ _ _WORK(_ _ _)_ _ _ - _ _ _ _OTHER _ _ _-_ _ _ _

EMAIL ADDRESS: ___________________________________

SOCIAL SECURITY NUMBER:___________________________

DATE OF BIRTH:(IF REQUIRED ON EXAMINATION ANNOUNCEMENT FORM)________________________

LEGAL RESIDENCE
	
NAME
	
YEARS
	
MONTHS
	
PLEASE CIRCLE SCHOOL DISTRICT IN WHICH YOU RESIDE

COUNTY OF:
					
Alexander	Batavia

Byron-Bergen	Elba	Le Roy

Oakfield-Alabama	Pavilion

Pembroke	Other__________

CITY,TOWN,OR VILLAGE OF:

STATE OF:

FOR CIVIL SERVICE USE ONLY

Date Received	                             Fee Paid	                  By____________

Approved	             Disapproved	         Conditional___________________

MSD 330 (11/2019)

	HIGH SCHOOL EDUCATION

Do you have a High School Diploma? □Yes □No
HIGH SCHOOL NAME	STATE
Date Graduated:

If not, do you have a GED?	□Yes □No
GED #	NAME OF ISSUING AUTHORITY

	
College, University, Professional or Technical School (print name and address of school)
		
Semester Credits Received
		
Major Subject or Type of Course
		
Type of Degree Received
		
Did you Graduate?
		
Date Received OR Expect to Receive It?

								

SPECIAL COURSES TAKEN:

NAME OF COURSE
	
CREDIT HRS.
	
NAME OF COURSE
	
CREDIT HRS.

				

TRANSCRIPT(S) OR DEGREE(S) (IF REQUIRED AS PART OF MINIMUM QUALIFICATIONS)

Copy Attached	Copy Requested

LICENSES/CERTIFICATES OR OTHER AUTHORIZATIONS TO PRACTICE A SKILL, TRADE,OR PROFESSION:

SKILL, TRADE, OR PROFESSION
	
LICENSE OR CERTIFICATE NUMBER
	
ISSUED BY: (Name or City, State, or Agency)
	
LICENSE DATES (Mo./Day/Yr.) From	To
	
PERMANENT

Yes No

							

DRIVER’S LICENSE INFORMATION:

	 NONE	            NEW YORK STATE	            OUT OF STATE (Indicate State) ________________ MOTORIST ID #                                                                                            	CLASS ________________ RESTRICTION(S)                           	ENDORSEMENT(S)                                 EXPIRATION DATE ____________

	*Yes	      No - Have you been convicted of a violation of law (Felony/Misdemeanor)?. (Omit any offense adjudicated in Juvenile Court or under a youthful offender law.) Convictions will not necessarily disqualify you from employment. *IF YES, YOU MUST ATTACH A LIST OF VIOLATIONS WITH DATES OF CONVICTION AND RESULTANT PENALTIES ON A SEPARATE SHEET OF PAPER.

	*Yes 	No - Are you under age 18? *IF YES, YOU WILL BE REQUIRED TO SUPPLY A WORK PERMIT.

WORK EXPERIENCE: YOU MUST COMPLETE THIS SECTION, EVEN IF YOU INCLUDE A RESUME. To receive credit for employment experience, this section MUST be completed thoroughly. Be sure to include specific dates, hours per week and earnings. Describe in detail all duties performed which are relevant to the position for which you have applied. List your most current employment first.

LENGTH OF EMPLOYMENT Month/Year to Month/Year
-
	
EMPLOYER
	
ADDRESS
	
CITY, STATE, ZIP CODE

HOURS WORKED PER WEEK:
	
PAID EXPERIENCE YES	NO
	
LIST OF DUTIES:

YOUR TITLE:

TYPE OF BUSINESS:

NAME AND TITLE OF SUPERVISOR:

REASON FOR LEAVING:

LENGTH OF EMPLOYMENT Month/Year to Month/Year
-
	
EMPLOYER
	
ADDRESS
	
CITY, STATE, ZIP CODE

HOURS WORKED PER WEEK:
	
PAID EXPERIENCE YES	NO
	
LIST OF DUTIES:

YOUR TITLE:

TYPE OF BUSINESS:

NAME AND TITLE OF SUPERVISOR:

REASON FOR LEAVING:

LENGTH OF EMPLOYMENT Month/Year to Month/Year
-
	
EMPLOYER
	
ADDRESS
	
CITY, STATE, ZIP CODE

HOURS WORKED PER WEEK:
	
PAID EXPERIENCE YES	NO
	
LIST OF DUTIES:

YOUR TITLE:

TYPE OF BUSINESS:

NAME AND TITLE OF SUPERVISOR:

REASON FOR LEAVING:

ADDITIONAL SHEETS MAY BE ATTACHED: Sheets must contain ALL information requested. (e.g. Number of hours worked per week, etc.) Full-Time is 30+ hours per week Part-Time is rated as follows:
0-09 hours/week = 0 10-19 hours/week = 1/4 20-29 hours/week = 1/2

VETERANS AND DISABLED VETERANS: If you have served or are currently serving in the Armed Forces of the U.S.A., in a designated time of war, and wish to claim additional examination credits, you must file a separate “Application For Veteran’s Credit” (VC-1 form) and provide appropriate military papers (DD214). You may request a VC-1 form to be mailed to you by placing a check
mark in this area (	).
IF YOU WISH TO CLAIM CREDITS, CHECK THE APPROPRIATE BOX:
DISABLED VETERAN NON-DISABLED VETERAN CURRENTLY IN ARMED FORCES

SPECIAL TESTING ACCOMMODATIONS: Check below if you require special testing accommodations due to :

Religious Observance	Disability	Alternate Date Needed
(Attach an explanation of your need for special testing accommodations on a separate sheet.)

Cross-filing - Exam Number & Title & Location of Other Exam(s) ________________

Please indicate the exam site at which you wish to be tested: _________________________

CHANGE OF ADDRESS: You must notify this agency immediately of any change of address. The number and title of the examination or eligible list must also be included in this notification. FAILURE TO COMPLY MAY RESULT IN YOUR NAME BEING REMOVED FROM AN ELIGIBLE LIST.

GENESEE COUNTY AN EQUAL OPPORTUNITY EMPLOYER

It is the policy of Genesee County Human Resources to provide accommodations in testing to individuals with disabilities and religious observers, and to provide for and promote equal opportunity in employment, compensation, without regard to race, color, creed, religion, sex, sexual orientation, national origin, age, disability, marital status, citizenship status, military or veteran status, criminal conviction status, predisposing genetic characteristics or genetic information, pregnancy, domestic violence victim status, or any other category protected by law.

PERSONAL INFORMATION PROTECTION STATEMENT

The information which you are providing on this application is being requested pursuant to 50.3 of the NYS Civil Service Law for the purpose of determining the eligibility of applicants to participate in an examination or a position applied for. The information will be made available only to those who have
a “need to know”, and will not be released to anyone else other than the applicant unless he/she has signed an appropriate release of information authorization. A candidate’s failure to provide this information may result in the disapproval of the application. This information will be maintained by the Genesee County Human Resources Director.

IMPORTANT: This section MUST BE completed. Failure to sign this section will result in disapproval of your application for employment or examination.

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.

I hereby authorize the release of information regarding prior employment history/records, educational records, law enforcement records, driver’s license and driving records, personal references and all like information bearing on my qualifications for this position to the appointing authority of all jurisdictions within the County of Genesee or his/her designee.

This authorization shall be valid for a period of two (2) years from the date of the execution of this document. A photocopy of this release will be as valid as an original thereof, even though the said photocopy does not contain an original writing of my signature.

Signature: 		 Date: ___________________________ (ORIGINAL SIGNATURE REQUIRED)

ALL STATEMENTS ARE SUBJECT TO VERIFICATION