Acs 21 Form – Fill Out and Use This PDF

This application is part of your examination. Answer all questions fully and carefully in ink or in typewriter. Some questions can be answered with an “x” in the box which applies to you. Attach additional sheets if necessary in order to give complete and detailed information.

	1. SOCIAL SECURITY NUMBER:					5. Are you taking exams with NYS State or any other County, Town or City that are being
						held on the same date as the exam(s) you are applying for with Albany County?
	-	-					Yes	No
						If yes, please attach the Cross-file Application and list all examinations. This can be found on our website.
	2. FULL NAME AND ADDRESS
						6. Are you requesting special testing accommodation(s), such as:
	Last Name	First Name	M.I.	1.			For a disability?		Yes	No
				2.			An alternate test date?		Yes	No
	Mailing Address					Please submit your request(s) for accommodations in writing on an attached sheet. You will have to provide
						documentation to support your request(s). If you request an alternate test date, please complete the Alternate
						Test Date Application.
	City	State	Zip Code

2a. RESIDENT STREET ADDRESS (if different from above):

7. CHECK APPROPRIATE BOXES:

A. Were you ever dismissed or discharged from any

Employment for reasons other than lack of work or funds?

Yes

No

2b. PHONE NUMBER (include area code):

B. Did you ever resign from any employment rather than

face dismissal?

Yes

No

Home

Other

Specify (work, cell, etc.)

2c. E-MAIL:

C. 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

3. RESIDENCE

honorable circumstances?

Yes

No

If you are applying for an open-competitive examination, please indicate, below, the

municipality/district in which you will be a legal resident prior to the examination date.

If you answer “YES” to any of questions above,

you must

give

specifics. (Attach

additional sheets if necessary.)

City or Village:

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

Town:

responsibilities of the position(s) for which you are applying.

County:

State:

8. SERVICE IN ARMED FORCES

Name of School District:

Have you ever served in the armed forces of the United States?

Yes,

No

If your answer is “yes” please go to item 9.

4. CITIZENSHIP & AGE

If you are not a citizen of the United States, do you have the legal right to accept employment in

9. VETERAN’S CREDITS

Do you claim additional credits as an honorably discharged war veteran?

the United States?

Yes, as a Non-disabled war veteran

Yes

No

Yes, as a Disabled war veteran

(Non-citizens may be required to produce Alien Registration Card at time of appointment)

No

Are you under 18?

Yes

No

If the answer is yes then see form ACS-21a (page 3)

If yes, or if minimum and/or maximum age limits are established for the position applied for,

If a motor vehicle license is required for the position for which you are applying, please

give the following:

enter your date of birth here:

Mo.

Day

Year

Chauffeur

Operator

Class:

Date of Expiration:

Number:

LEAVE THIS SPACE BLANK

THIS DECLARATION MUST BE COMPLETED: I declare, subject to the penalties of

perjury, that the statements made in this application (including statements made in any

accompanying papers) have been examined by me and to the best of my knowledge and belief

are true and correct.

Exam Number

Approved by

Date Received

Pending

Signature of applicant

Date

Fee $

Disapproved by

State any other names by which you have been known

Education

Or a High School Equivalency (GED) Diploma?

Yes

No

College/University

Dates of attendance

Type of Course

Number of College

Did you

Type of degree

Date Degree

Name of School and City in which located

(Month/Year)

of Major

Credits Received

Graduate?

received?

Received or

From To

Expected

College Transcripts (omit if not applicable)

Is transcript submitted herewith?

Is transcript on file with Albany County Civil Service?

Is College to forward transcript?

Professional Schools, Residencies, Military Service Schools, Other Schools

Do you have a license, certificate, or other authorization to practice a trade or profession?

Yes No

Name of trade or profession

Granted by (Licensing agency)

State of

.

Initial date of Licensure

License #______________________

Currently Licensed

From: Mo.

Yr.

To: Mo.

Yr.

EXPERIENCE: Describe under the headings given below any employment or occupation 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. Begin with your most recent employment and work backward consecutively to your first one. Applicants may be required to furnish satisfactory proof of experience claimed. A resume is not a substitute.

Length of Employment					Name of Employer			Address		City and State
From: Mo.	Yr.	To: Mo.	Yr.
Paid?	# of hours/week			Type of business		Title			Name and title of Supervisor
Yes / No
Describe duties:
							Reason for Leaving:
Length of Employment					Name of Employer			Address		City and State
From: Mo.	Yr.	To: Mo.	Yr.
Paid?	# of hours/week			Type of business		Title			Name and title of Supervisor
Yes / No
Describe duties:
							Reason for Leaving:
Length of Employment					Name of Employer			Address		City and State
From: Mo.	Yr.	To: Mo.	Yr.
Paid?	# of hours/week			Type of business		Title			Name and title of Supervisor
Yes / No

Describe duties:

Reason for Leaving:

IF MORE SPACE IS REQUIRED, USE ADDITIONAL SHEETS ARRANGED IN THE SAME MANNER AND ATTACH SUCH SHEETS TO TOP OF PAGE

THE NEW YORK STATE HUMAN RIGHTS LAW (ARTICLE 15) PROHIBITS DISCRIMINATION IN EMPLOYMENT BECAUSE OF AGE, RACE, CREED, COLOR, NATIONAL ORIGIN, SEXUAL ORIENTATION, MILITARY STATUS, SEX, MARITAL STATUS OR DISABILITY. 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, SEXUAL ORIENTATION, MILITARY STATUS, SEX, MARITAL STATUS, OR DISABILITY IN CONNECTION WITH EMPLOYMENT BY THE MUNICIPALITY.

ADDITIONAL CREDITS FOR VETERANS AND CHILDREN OF FIREFIGHTERS AND POLICE OFFICERS

KILLED IN THE LINE OF DUTY

INSTRUCTIONS AND INFORMATION

***If you are claiming additional credits as a disabled or non-disabled war veteran, you must submit a copy of your separation papers (DD214) within two months of the last filing date for examination.

A. VETERANS’ CREDITS

Have you used your veterans’ credits for permanent appointment or promotion in New York State or any of its civil divisions since January 1, 1951?

***If you answer yes, you cannot use veterans’ credits again (NYS Civil Service Law §85.4) unless you had been certified as a non-disabled war veteran and became a disabled veteran after that.

VETERANS’ CREDITS: For the purpose of claiming veterans’ credits on a civil service examination, an applicant must have been honorably

discharged or released under honorable circumstances after serving on active duty with the armed forces of the United States during time of war.

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 in the case of promotional examinations) added to their earned scores, and provided they have not previously used such credits to obtain permanent appointment or promotion. Veterans may determine to waive the use of their credits at any time up to the time of permanent appointment or promotion.

Veterans who are eligible for additional credit must submit a copy of their separation papers (DD-214) within two (2) months of the last filing date for the examination. Veterans’ credits can only be added to a passing score on the examination.

Effective January 1, 1998, the State Constitution was amended to permit a candidate currently in the armed forces to apply for and be conditionally granted veterans’ credits in examinations. Any candidate who applies for such credit must provide proof of military status to receive the conditional credit. No credit may be granted after the establishment of the list. It is the responsibility of the candidate to provide appropriate documentary proof

indicating that the service was in time of war, as defined in Section 85 of the Civil Service Law, and that the candidate received an honorable discharge or was released under honorable conditions in order to be certified at a score including veterans’ credits.

Effective January 1, 2014, the State Constitution was amended to permit disabled veterans to use additional credits on civil service examinations to obtain a second appointment or promotion.

If a veteran previously received five (non-disabled) points on an open-competitive examination and subsequently became certified as disabled, he or she would be entitled to receive another five (disabled) points on a subsequent examination whether an open-competitive or a promotion examination.

If a veteran previously received two and one-half (non-disabled) points on a promotion examination and subsequently became certified as disabled, he or she would be entitled to receive another seven and one-half (disabled) points on a subsequent examination whether an open-competitive or a promotion examination.

If you received or expect to receive an honorable discharge from the Armed Forces of the United States, as a war-time veteran or disabled veteran as defined below, you may claim extra credits to be added to your exam score, if you pass. The Armed Forces of the United States means the Army, Navy, Marine Corps, Air Force and Coast Guard, and all components thereof, and the National Guard when in the service of the United States pursuant to call as provided by law on a full-time, active duty basis other than active duty for training purposes.

Discharged veterans are required to submit a copy of their DD-214 discharge papers. Active duty members of the Armed Forces must submit proof of active duty status, such as current Military I.D., Military Orders or other official military document that substantiates active duty status. To claim credits as a Disabled Veteran, you must be entitled to receive payments for a service- connected disability (rate at 10% or more) incurred during time of hostile action or war.

CHECK AND INDICATE BELOW THE TIME PERIODS YOU SERVED OR ARE SERVING IN THE ARMED FORCES OF THE UNITED STATES

FROM MO/YR TO MO/YR

World War II: ……………………………………………………….……December7, 1941 – December 31, 1946

US Public Health Service:………………………………………………...July 29, 1945 – September 2, 1945

Korean Conflict:…………………………………………………….……June 27, 1950 – January 31, 1955

US Public Health Service:…………………………………………..……June 26, 1950 – July 3, 1952

Vietnam Conflict:………………………………………………….…...…February 28, 1961 – May 7, 1975

Hostilities in Lebanon***:………………………………………….….…June 1, 1983 – December 1, 1987***

Hostilities in Grenada***:………………………………………….….…October 23, 1983 – November 21, 1983***

Hostilities in Panama***:…………………………………………….…..December 20, 1989 – January 31, 1990***

Persian Gulf Conflict:……………………………………………………August 2, 1990 – (	)
Active Duty:……………………………………………………………

***For these service dates Veterans must have received the Armed Forces Expeditionary Medal for Service in Zone of Conflict.

B. ADDITIONAL CREDITS FOR CHILDREN OF FIREFIGHTERS AND POLICE OFFICERS KILLED IN THE

LINE OF DUTY: In conformance with section 85-a of the Civil Service Law, children of firefighters and police officers killed in the line of duty shall be entitled to receive an additional ten (10) points in a competitive examination for original appointment in the same municipality in which his or her parent has served. If you are qualified to participate in this examination and are a child of a firefighter or police office killed in the line of duty in this municipality, please inform this office of this matter when you submit your application for examination. 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.

_________________________________	____________________
Signature of applicant applying for extra credit	Date

ACS-21a